HomeMy WebLinkAboutSeptic Pumping Slip - 729 BOXFORD STREET 12/19/2017 ED
Commonwealth of Massachusetts' � "iV
City/Town of NORTH ANDOVER MASSACHUSETT
System Pumping Record
Form 4 10vq`�
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 -._....._� ' z�
only the tab key Address
to move your North Andover -�` -
cursor-do not MA
use the return Clty/Town 01845
State _._ —....__.._....�....�.w..�_
key. Zip Code
2. System Owner:
Name --
Addres�ent from loc
atran}� ---.-----_. --
City/Tawn
State Zi Code
e@e
� Y � � -
Tphone Number -
B. Pumping Record
1. Date of Pumping Dat - Z 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Q4Septic Tank
P ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ No If yes, was it cleaned?
El Yes ❑ No
5. Condition of Syste
6. System Pumped By:
Name Vehicle Licenseb,;LZ`
Wind River Environmental
Company �— --
f
7. Location where contents were disposed:
Signature of Hauler ` dy Date
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06/03
System Pumping Record•Page 1 of 1