HomeMy WebLinkAboutSeptic Pumping Slip - 20 OLYMPIC LANE 4/20/2017Commonwealth of Massachusetts
% City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
IA
When filling out Sys e�LOCatiO:
forms on the
��J D � dj/fr
computes, use �/1
only the tab key Address
to move your North Andover
cursor - do not
use the return
CitylTown
key. 2. SystetrOwner:
fU' 'u1 b0-7/4i 1./1/5‘54
Name
MA
State
01845
Zip Code
Address (if different from location)
City/Town
State
Teleph•ne Number
Zip Code
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
1,►
2, Quantity Pumped:
Gallons
Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syste
Nam
Wind River Environmrental
Company
7. Location wherJcc#Ule disposed:
ich, MA.
Signal Ha er
http://www.mass.goy/dep/water/approvals/t5forms.htm#inspect
Vehicle Licen§e Number
t5form4.doc• 06103 System Pumping Record • Page 1 of 1