HomeMy WebLinkAboutSeptic Pumping Slip - 71 JOHNNY CAKE 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 1. SysteL a ion:
Forms on the m "MV-1
computer,use
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. System Owner:
b
Name
Address(if different from location)
city/Town State Zin Code
Ias- I
Telephone Number
B. Pumping Record
S CX)
1. Date of Pumping pate
2. Quantity Pumped:
Gallons
3. Type of system: F1 Cesspool($) Septic Tank E] Tight Tank
M Other(describe):
4. Effluent Tee Filter present? El Yes [�No If yes, was it cleaned? El Yes ❑ No
5. Condition of System:
C—)
6. System PumpedBy:
Name
Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed* Haverhill WWTP
Q 6 Porter St
Bradford, Ma 01
-Signature of Hauler
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4,doc-06/03
SYStOrn Pumping Record-Page 1 of I