HomeMy WebLinkAboutSeptic Pumping Slip - 345 BOSTON 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 tilling out I. System Location:
forms onthe
computer,use
only the tab key
Address
to move your North Andover
cursor-do not MA 01845
use the return City/Town
–§f-a�te Zip--C —e
key.
411-- 2. System(owner:
b
W0
Name
Address—(if different from�focation)
-61,1�yrrown
State
/ -7SF7Z- -Z'pc
Telephone Number
B. Pumping Record
1'7
1. Date of Pumping 2. Quantity Pumped:
Ya—te .......//j
Gallons
3. Type of system: ❑ Cesspool(s) 2KSeptic Tank E] Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? n YesX*fl No If Yes, was it cleaned? El Yes ED No
5. ConditionSystem:
O
6. System mped y:"
Name
Vehic1d License Number
Wind River Environmental
Company
7. Location where conten s weredisposed.,
Af
-Signature auler
Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/o3
System Pumping Record•Page 1 of 1