HomeMy WebLinkAboutSeptic Pumping Slip - 200 RALEIGH TAVERN LANE 12/19/2017 - Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHIUM10�1� M��
.° System Pumping Record
ti
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 tilling out 1. System Location: t
forms on the �}} �) O LAI computer,use V i✓ _� c C r'4V C -'/
only the tab key Address `_ _. _ ---to move your North Andover v
cursor-do not MA
use the return CitylFown _ — 01845
State _ Zip Code
key. _. .
2. 5yste wn�r:
rad b l
Name
Address(if different from location)
B. Pumping Record
1. Date of Pumping ,� -
bate — 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 6�jSeptic Tank
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ' No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition
� stem:
6. System P ed
yy
Vehicle License Number
Wind River Environmental,
Company #• _ ��-
al� S
7. Loca#ion v .,* t ed:
Signatur of ler Dake
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
i
t6form4.doc•06/03
System Pumping Record•Page 1 of 1 J