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Home My WebLink AboutSeptic Pumping Slip - 93A TURNPIKE STREET 5/11/2017 VR Commonwealth of Massachusetts � � �� A��c�:�7V City/Town at NORTH„ ANDOVER, MASACHUETTZ System Pumping Record Form 4 DEEP 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 only the tab key Address to moue your North Andover MA 0:1845 cursor-do not City/Town State Zip Coda use the return key, 2. System Owner- Name Gl t ress�(if different ff opati❑n) City/Town Stat E Code Telephone Number S. Pumping Record 1, pate of Pumping is 2. Quantity Pumped: 'ISO b Da 3. Type of system: ❑ Cesspool($) ❑ Septic Irank . Q Tight Tank Other(describe): -u 4. Effluent Tee 51[ter present? © Yes ❑ No If yes.vats It cleaned? ❑�Yes ❑ No i 6. Condition of System: 6, System:Pumped By; NaMe Vehicle License Number Wind Diver Environmental , TEt+ ARTS'i SEPTIC SERVICE Company 58 SOUTH TH KIMBAL t,,IST. 7. Location where contents were disposed: BRADFOR D, mA oi e3s <�Mgnature� of'Hauler http://www.mass.gov/deplwater/approvels/t5forms.htm#lnspect t5form4.doc•06/03 System Pumping Recard»Page 1 of 1 i if