HomeMy WebLinkAboutSeptic Pumping Slip - 315 BERRY STREET 11/27/2017 Commonwealth of Massachusetts
w 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 I. System LOC n:
forts on the _
computer,use _ ,�_ r{{
only the tab key AdUress
to move your North Andover
cursor-do not MA 01845
use the return CityfTown StatZip Code
key, e
2. System Owner:
b �..�, .
Name
Address(if different from location
City/Town State zip
7
Teleph ne Number
B. Pumping Record
!. Date of Pumping �{
2. Quantity Pumped:
t Ste.)
Dat Y p Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy tern:
6. System Pu
'�jRed By:
Name Vehicle License Number
Wind River Environmental
Company
Haverhill VVVVTP
7. Location where contents were disposed: 40
Porter St
e
M3 0183
97 1 qW,-T IS2
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
t5forrn4.doc•06/03
System Pumping Record•Page 9 of 1