HomeMy WebLinkAboutSeptic Pumping Slip - 103 TUCKER FARM ROAD 11/27/2017 Commonwealth of Massachusetts
H 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
Important:
When filling out 1. System Location:
forms on the `--�
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System wrier:
rad b �G�
Name
Address(if different from location)
City/Town State Zip Code
Tefephbne Number
B. Pumping Record r
ho I
1. Date of Pumping Io� 2. Quantity Pumped:
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 Bim.,
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
riavernill VVwTP
40 S Porter St
Signature of Hauler
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect (97$) 74_2382
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