HomeMy WebLinkAboutSeptic Pumping Slip - 325 BERRY STREET 4/24/2017Address
North Andover MA 01845
City/Town
Commonwealth 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:
When filling out "1. System Location:
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key. 2 System Owner:
Name
State Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 1 Z�� ' i 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Lyt Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name
Wind River Environmental
Company
7. Location where contents were disposed:
Vehicle License Number
Signature of Hauler Date
http:llwww.mass.gov/deplwaterlapprovalslt5forms.htm#inspect
I.W.W T.P
Ipswich, MA.
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1