HomeMy WebLinkAboutSeptic Pumping Slip - 29 WILDWOOD CIRCLE 12/19/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER. MASSACHUSETTS
System Pumping Record ----------
Form 4 MOV kjo
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
only the tab key Address
to move your
cursor-do not North Andover MA
use the return Ziiy—fl-ov�n ��� 01845
key. State
2. System Owner:
b
Name
Ad-Iress(—if different from�Iocation)
'61-tyf
Zip Code
-�LO-Y5
Telephone%mba, — --
B. Pumping Record
1. Date of Pumping
1 Type of system: ❑
bate 2. Quantity Pumped: Gallons
Cesspool(s) qj Septic Tank F-1 Tight Tank
El Other(describe):
4. Effluent Tee Filter present? R Yes No If yes, was it cleaned? El Yes El No
5. Condition of System.
6. System Pumped By:
L
Wind River Environmental Vehicle License NumberZ—om`pa�ny —'----
7. Location where contents were disposed:
-Signature of Hauler'--'-----
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect Date
NON 06't
t5forrn4.doc-06/03
44�()Z, System Pumping Record-Page 1 of i
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