HomeMy WebLinkAboutSeptic Pumping Slip - 137 FOREST STREET 5/17/2017Important:
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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
1. System Location:
17 r? 1--or;54-
Address
North Andover
CitylTown
2. System Owner:
Q 410
Name
/3ocr
MA
State
01845
Zip Code
Address (if different from location)
City/Town
S ate 9 Zip CacLdje
J o S
U
T-lephone Nu ber
B. Pumping Record
1. Date of Pumping /17/f / 2. Quantity Pumped: 2 30 0
Date Gallons
3. Type of system: ❑ Cesspool(s) I -Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:
6. System Pumped By:
J O COI S C
Name
Wind River Environmental
Company
7. Location where contents were disposed:
Vehicle License Number
I,W.W.T.P. 'VN `1113Ynsdi
Ipswich, MA, TEAM'
AM'
/C 21/7
gnature of Hauler Date
http://www.mass.govldeplwater/approvals/t5forms.htrn#inspect
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1