HomeMy WebLinkAboutSeptic Pumping Slip - 171 FOREST STREET 11/27/2017 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
Important:
When filling out I System Location:
forms on the
computer, use
.......... -Cl�
only the tab key Address
to move your
North Andover
cursor-do not MA 01845
use the return City/Town State
Tip—Code
key,
2. Sys�yOwn
b
Name
Address(if different from location)
Zk711T0wn-------
p Code
Telephone Number
B. Pumping Record
1. Date of Pumping -Date
2. Quantity Pumped.,
(—+�O
Gallons
3. Type of system: El Cesspool(s)
Septic Tank ❑ Tight Tank
E3 Other(describe):
4. Effluent Tee Filter present? Ej Yes No If Yes, was it cleaned? ❑ Yes El No
5. Condition of System:
C4
6. System Pumped By:
q-c"
q
Name Vehicle License Number
Wind River Environmental
-Company
7. Location where contents were disposed:
erniii vMW
4D-S-P0Tt&r-6t tic
0i
Signature of Hauler RMdftgd,- Ma 83U
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect (9781374-2382
t5form4.doc-06/03
system Pumping Record-Page 1 of 1