HomeMy WebLinkAboutSeptic Pumping Slip - 280 REA STREET 5/10/2017 Commonwealth of Massachusetts
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City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Foran 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 ff� c� �� -.��......— ' ..t....._...... .__ _.. _ _.._........
only the tab key Address
to move year North Andover MA 01845
cursor-do not __... ___— _.._ �. ...
use the return Crtyrfown State Zip Code
key. 2. System Owner:
f q k
Name
' Address(if different from location
City/Town State Zip Code
Telephone'" . . _ ........_ t
Number
B. Pumping Record
o.
1. Date of Pumping - - - 2. Quantity Pumped:
ed; r
p Date Gallons
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3. Type of system: El Cesspool(s) [ Septic Tank [ ] Tight Tank
❑ Other(describe):
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4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5, Condition of Systen,�
`"...... ._..._._ _ __....._.. ._...__ _.....,.._._ _..._ __._. _
6. System Pumped By:
Name _ 1 - __. Vehc6License Number
Wind River Environmental
Company
7. Location where contents were disposed:
AO 6 a . a
Signature of Harder Date " ich,
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doa 06/03 System Pumping Record-Page 1 of 1