HomeMy WebLinkAboutSeptic Pumping Slip - 54 TUCKER FARM ROAD 11/27/2017 Commonwealth of Massachusetts
= City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Form 4
•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 the
computer,use �...�2
only the tab key Address
to move your North Andover MA
cursor-do not 01845
use the return CitylTown State Zip Code
key.
2. Syste Ownr:
Name
Address(if different from location)
Cityfrown Stat
Te ephone Number
B. Pumping Record
uatL 2, Quantity Pumped:
1. Date of Pumping
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes,?f7No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition oy
6. Syste Pu ed By
Name Vehicle License Number —
Wind River Environmental
Company
7. Location where contents A,ere disposed:
joch XX A
�"Y�
Signal auler �o
hftp://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
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