HomeMy WebLinkAboutSeptic Pumping Slip - 336 SHARPNERS POND ROAD 11/27/2017 Commonwealth of Massachusetts
City/Town of NORTH AND
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 on the
computer,use
only the tab key Address
to move your
North Andover
cursor-do not MA
01846
use the return City/Town
Zap Code
-�tate
key-
40---h 2. System Qwner:
b
Name
Address(it different from location)
Ci�frown
ate-
ate
Zip Code
JV-
el phone Number
B. Pumping Record
1. Date of Pumping .2
2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank [I Tight Tank
El Other(describe):
4. Effluent Tee Filter present? es E] No If yes, was it cleaned?,-M Yes ❑ No
5. Condition of System:
6. System mpe y:
Name
W IVVTP Vehicle License Number
Wind River Environme P ,,)
-
V;�O#
company
13radford
sV69 01836
7. Location where contorwe
0 s
2382"
7 :�M12
-
77-
Signature Hauler Date
http://www.mass,govldep/water/approvaIs/t5forms.htm#inspect
t5form4.doc-06/03
System Pumping Record-Page 1 of I