HomeMy WebLinkAboutSeptic Pumping Slip - 555 FOREST STREET 5/11/2017 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 S- ho cc
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return CityfTown State Zip Code
key.
2. System Owner:
b C
Name
Address{if different from location)
-6-1-ty—/T.Wn Sta Zi ode
-Telephone Number
B. Pumping Record
c)1
Gallons
2. Quantity Pumped:
1. DateofPumping 1 2
at
3. Type of system'. El Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? E] Yes EXNo If yes, was it cleaned? M Yes E] No
5. Condition of System:
6. System Pumped By:
C,
....................
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Haverno! VVVVTF"
Signature of Hauler
4 F)orter-St—
http:Ylwww.mass,gov/dep/water/approvals/t5forms.htm#inspect
Brfid fOrd, Ma 01835
(978) 374-2382
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