HomeMy WebLinkAboutSeptic Pumping Slip - 271 CANDLESTICK ROAD 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. Syste Location: /
forms the
computer,use
only the tab key Address
to move your North Andover
cursor-do not MA 01845
use the return Cityfrown State —
Z€p Code
key
2. Systeawnk
bC�
Name
Address(if different from location)
CltyfTown Stat
Zip Code
7 �-zazf>
Telephone Number
B. Pumping Record
1. Date of Pumping Date / / I 2. Quantity Pumped:
p Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes Al No If yes, was it cleaned? El Yes ❑ No
5. Condition of Sy m:
6. System P ed
Name
Vehicle License Number
Wind River Environmental
company
7. Location where contents were disposed:
•Vt.W.T.P.
sw1 A'
Signature.of H r Date
http://www.mass.gov/dep/ r/approvals/t5forms.htm#inspect
tsform4.doc•06/03
System Pumping Record•Page 1 of 1