HomeMy WebLinkAboutSeptic Pumping Slip - 1 LACY 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. System Location:
forms the f I Gl C I
computer,use
only the tab key Address
to move your North Andover
cursor-do not MA 01845
use the return Gityfl own State Zip Code ___._
key,
2. System Owner:
�I C-C t
Name
Address(if different from location)
Cityffown State
q,7 f. � - Zip Cade
Telephone Number
B. Pumping Record
7. Date of Pumping DateLo _zU -:--/-72. 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 By:
Name
Vehicle license Number
Wind River Environmental
Company
7. Location where contents were disposed:
oil
4� �t 4 X111 �V f-
Signature of No� Date
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