HomeMy WebLinkAboutSeptic Pumping Slip - 160 FARNUM STREET 6/2/2017Important:
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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:
C;
Address
North Andover
City/Town
ci r.,./1 (A' I4A
2. System Owner:
Name
Address (if different from location)
City/Town
MA
State
01845
Zip Code
State Zip Code
(71
7f2, eoci 7
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
( 5 ZI
Gallons
3. Type of system: 11] Cesspool(s) a Septic Tank ID Tight Tank
LI Other (describe):
4. Effluent Tee Filter present? El Yes [ No If yes, was it cleaned? 11 Yes [1] No
5. Condition of System:
COCk'
6, System Pumped By:
e_
Name
Wind River Environmental
Company
7. Location where contents were disposed:
Vehicle License Number
Signature of Hauter
http://wvvw.mass.govIdep/water/approvals/t5forms.htm#inspect
Date
t5form4.doc06/03 System Pumping Record -
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