HomeMy WebLinkAboutSeptic Pumping Slip - 90 GRAY STREET 11/27/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
rl
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
SyStM Locati
forms on the
computer,use
only the tab key Address
to move your North Andover
cursor-do not MA 01845
use the return Cityrrown State
ZipCodekey.
2. SysteOwner:
b
Name
Address(if different from location)
cityrrown
State
Z' Code
Telephone Number
B. Pumping Record
1. Date of Pumping
'Date Quantity Pumped:
Gallons
3- Type of system: El Cesspool(s) Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If Yes, was it cleaned? ❑ Yes Ej No
5. Condition of Sys m:
6. Syste P pe B
Name
Vehicle License Number
Wind River En)Uionrnental
Company
7. Location
ri&vore,disposed:
Signature user
Date
t.
http://www.mass.gov/dep/water/approvals/t5 QPhtmMAspect
t5form4.doo-06/03
System Pumping Record-Page I of 1