HomeMy WebLinkAboutSeptic Pumping Slip - 169 GRAY STREET 11/27/2017 Commonwealth of Massachusetts
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 1. System Location-
forms to the
computer,use
only the tab key M r�ess
to move your
North Andover
cursor-do not MA 09845
use the return City[Town State `
key. Zip Code
2. System Owner:
b
Wa
Name
Address(if different from location)
ClvTown State
zip de
Telephone Number --
B. Pumping Record
1, bate of Pumping IL 2
pat Quantity pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Na If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
s
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass-gov/dep/water/approvals/t5forms,htm#inspect
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