HomeMy WebLinkAboutSeptic Pumping Slip - 325 JOHNSON STREET 11/27/2017 g
Commonwealth of Massachusetts
9. City/Town of NORTH ANDOVER MASSACHUSETTS
A3 USETTS
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 I
Stem Location:
forms on the
computer,use
only the tab key Address
to move your
North Andover
cursor-do not MA 01845
use the return City/Town
Tta�teTip—Code
---
key-
2. System Owner:
V52L—ji b
A<-
Name
Address(if different from location)
Cityrrown
State Zin Co
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 1 2. Quantity Pumped' 0>0
Gallons
3. Type of system: ❑ Cesspool(s) E,;(Septic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? 0 Yes El No
5. Condition of System:
z5c-
6. System Pumped By:
V,
Name 7
Vehicle License Number
WindRiver Environmental
Company
7. Location where contents were disposed: Havernill vVVV-j-p
40 8 P-o
r
ter St
Signature of HaulerBradford, Ma 01835
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03
System Pumping Record-Page 1 of I