HomeMy WebLinkAboutSeptic Pumping Slip - 78 VEST WAY 12/19/2017 - r ypurlp�'3
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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASS,A►CHU►SETr
A.
System Pumping Record
Form 4z
k
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 wing out I. System Loc tion:
forms on the
computer,use
only the tab key Address
to move your North Andover
cursor-do not Cit /T,own `m" -�---------- MA 01845
use the return Y —__..
State _._...__�_.._�._._�...
key. Zlp Code
2. Syste�ct er:
b
Name
' Address(if different from—location)
Cityffown ------------- State
Zip Code
�,
7 � 3 (.1
Telephone Number —
B. Pumping Record
<� +
1. Date of Pumping — �.I�-
aate ?. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic 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:
Name
vehicle Ltcense Number —
Wind River Environmental
Company _.—_ -_..___.
7. Location where contents were disposed:
10 S Porter St
Signature of Mauler --
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect grad rd,
' 51N 111,7/1,-2382
1,7/1- 3 2
t5form4.doc•08103
System Pumping Record•Page 1 of 1