HomeMy WebLinkAboutSeptic Pumping Slip - 143 PHEASANT BROOK ROAD 11/27/2017 Commonwealth of Massachusetts
r City/Town of NORTH AND 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
important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your North Andover
cursor-do not MA 01845
use the return City/Town State - —
key. Zip Code
2. System O ner:
bc, r s-
c=�
Name
Address(if different 4rom lova i
t on)
City/Town Stated Zip Code
q
Telephone Number
B. Pumping Record
s�
1. Date of Pumping �p 2. Quantit Pum ed:
te y p Gallons
3. Type of system: ❑ Cesspool(s) [.Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company —
7. Location where contents were disposed:
Haverhill WWT P
Signature of Hauler
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect (978) 374-2382
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