HomeMy WebLinkAboutSeptic Pumping Slip - 143 LACY STREET 5/20/2017Important:
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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.
Systm Location:
Address
North Andover
S1
CitylTown
2. b System �e e
Name
MA 01845
State
M Y h
Zip Code
Address (if different from location)
City/Town
Sr}7g7 ZIp/Id6
Telephone Number
B. Pumping Record
a 5 /.26117
1. Date of Pumping Date 2. Quantity Pumped:
is°�
Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other (describe): ,_
4. Effluent Tee Filter present? jr Yes ❑ No If yes, was it cleaned? Ly' Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Wind River Environmental
Company
7. Location where Conte t e sposed:
gnat R tb
http:Ilwww.mass.govfdeply rav hntm#inspect
o / o/ 1 7
Date
15form4.doa 06/03 System Pumping Record Page 1 of 1