HomeMy WebLinkAboutSeptic Pumping Slip - 208 OLD CART WAY 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. System Location:
forms onthe
computer,use cet
only the tab key Address
to move your
North Andover
cursor-do not MA
use the return City/Town 01845
State -Zip�Code
key.
2. System Owner:
b
Name
Address(if different from location)
-
Ity TownZip Code
'
State
'Felleon —mbe�r�-�2,
B. Pumping Record
1. Date of Pumping 10 Ll 2. Quantity Pum
Date ped:
Gallons
3. Type of system: El Cesspool(s) ED-S-e-'ptic Tank Ej Tight Tank
El Other(describe):
4. Effluent Tee Filter present?
9--Y-es El No If yes, was it cleaned? E��es El No
5. Condition of System:
6. Sys em Pumpp4 BNk.
Name
Vehicle License Number
Wind River Environmental
-Company
7. Location where contents were disposed:
Ips
Signature of Hauler Date
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