HomeMy WebLinkAboutSeptic Pumping Slip - 352 FOSTER STREET 5/4/2017ECEI
Commonwealth of Massachusetts
N (2.* NUR1trii N1.„,) !yr
System Pumping Record
City/Town of NORTH ANDOVER, MASSACHUSETTS KALuIDEPARr 141
.;t
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, Systpm Loc tio
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Address
North Andover
City/Town
2. SystemZner:
b
Name
Address (if different from location)
City/Town
MA
State
01845
Zip Code
C°--1";;±
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: 0 Cesspool(s) Septic Tank 0 Tight Tank
ri Other (describe):
4. Effluent Tee Filter present? 0 Yes Ej No If yes, was it cleaned? 0 Yes 0 No
5. Condition of ystem:
6. System Pum
Name
Wind River Environmental
d By."
171/1
Date 2. Quantity Pumped:
Vehicle license Number
Company
7. Location where contents were disposed:
nature of Hauler Dale
http://www.mass.govidep/water/approvalsit5forms.htm#inspect
Gallons
I.W.W.T.P.
Ipswich, MA.
15form4.doc• 06/03 System Pumping Record • Page 1 of 1