HomeMy WebLinkAboutSeptic Pumping Slip - 130 LACONIA CIRCLE 5/15/2017 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 1= Ur-\ C.
Gniy the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
-- ----------
...........
Name
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date' 2. Quantity Pumped: Gallons
3. Type of system: El ACesspool(s) S eptic Tank El Tight Tank
F1 Other(describe):
4. Effluent Tee Filter present? El Yes L6 No If yes, was it cleaned? E] Yes E] No
5. Condition of S stem:
6. System Pumped By:
C:, ............. .............
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
... .............
Signature of Hautec Date
http://www,mass,gov/dep/waterlapprovals/t5forms.htm#inspect I.WW.TP.
Ipswich, MA.
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