HomeMy WebLinkAboutSeptic Pumping Slip - 55 EQUESTRIAN DRIVE 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 on the
computer,use �_ t/" / yj
only the the tab key Address
to move your north Andover
cursor-do not MA 01846
use the return City/Town State -
key.
Zip Cade
2. System gwner:
b 3.k !"L)
Name
Address(if different from location
CiEylTown State -
G��j�,��,K fY 11p Ca
Telephone Number
B. Pumping Record
1. Date of Pumping aat�e'—t� 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ,( Septic Tank ❑ Tight Tank
❑ Other(describe): \ —
4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? El Yes ❑ No
5. Condition of System:
6. System Pu ed By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Sign of Hauler tate
http://www.mass.gov/dep/water/approvals/t5forms.htm#jnspect
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