HomeMy WebLinkAboutSeptic Pumping Slip - 176 VEST WAY 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 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:
forms on 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-Code
2. System Owner:
Name _
Address{if different from location?
CitylTown Stat _
Z Code. �..-.-
'telephone Number
B. Pumping Record
1, Date of Pumping - f !� 2
SO
a e Quantity Pumped: 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 System:
6. System Pumped By;7
Name � �
Vehicle License Number
Wind River Environmental
company
7. Location where contents were disposed: -iaVerhlll VVWTP
40 S Porter St
Signature of Hauler
http.,//www.mass.gov/deplwater/approva Is/t5forms,htm#i ns pect
t5form4.doc•06103
System Pumping Record•Page 1 of 1