HomeMy WebLinkAboutSeptic Pumping Slip - 200 GRANVILLE LANE 11/27/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVERL.MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by focal 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:
fames the •) � ! / ��
computer,use
only the tab key Address
to move your North Andover —
cursor-do not MA
01845
use the return City'Town State ----
key. Zip Cade
2. Systerla_Owner:
V� b {� t
Name _
Address(if different from location
)
Cityr own
State7 f- p Code
Telephone Number
B. Pumping Record
�. 7
1. Date of Pumping date- 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes KNO If yes, was it cleaned? ❑ Yes ❑ No
S. Condition of Sy/st rr1:
6. System Pu d Bye `
Name --pp Vehicle License Number
Wind River Environmentf j°�y
Company
7. Location wt.i�re coil + gy�0&rip%`
r a
82 r
/ s
Signa of Hauler Date — p
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect G
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t5form4.doc•06!03
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