HomeMy WebLinkAboutSeptic Pumping Slip - 1187 SALEM 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 anthe
computer,use
only the tab key Address
to move your
North Andover
cursor-do not MA 01846
use the return City/Town State
key. Yip—Code -
2, System Owner:
rrtr AC4 k be4�
Name
Address(if different from location)
CItylTown -9t—ate 117P Code
9172'f-
Telephone Number
B. Pumping Record
1. Date of Pumping
-61—te -71-- 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If Yes, was it cleaned? El Yes ❑ No
5. Condition of Syste
6. System Pumped By:
Name
Vehicle Ucens
Wind River EqvirMmental
.Q t
Iter
brA x Iter
dOmPlly
(97, (Ifor'U44,
7. Location w '19 At%'%tMposed: 8) "3 1101
' 836
ffr'id'f 6 r,I
ti 374-2-3
82
--
Signature of—Hauler Date
http://www.mass.gov/dep/water/approVals/t5forms,htm#inspect
t5form4.doc-06/03
System Pumping Record-Page 4 of I