HomeMy WebLinkAboutSeptic Pumping Slip - 1072 JOHNSON 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 focal Boards of Health. The System Pumping Record must
be submitted to the focal Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your North Andover
cursor-do not MA
use the return city/Town 01845key.
State Zip Code
2. System Owner:
G(Ac
Name
�.,...y„� Address(if different from location)
Clty/Town State — Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2 Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspooi(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 wh 41lk tdIWW d: ��tc3i/e;t�bi4( it d i
40Poder St 40 S Porter St
Bradford, Ma 01335 Bradford, Ma 0133 _
Signature of Ha. Date
http://www.mass.gov/dep/water/approvals/t5forms,htm- inspect
B
p
R
t5form4.doc•06103 System Pumping Record•Page 1 of 1