HomeMy WebLinkAboutSeptic Pumping Slip - 1620 SALEM STREET 12/19/2017 FIECEIVED
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSE ')& i,VX,10�,�i AMMR
TTj
System Pumping Record
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 filling out 1. System Location*
forms on the
computer,use
only the tab key AddAressL—
to move your North Andover
cursor-do not MA 01845
use the returnfiewn
key. stat —PCade—---—-----
VQ 2. Sy"Name Mewner ,
b 11 xle
Address(if different from location) -----
r
Telephlo —ef4—umbe
B. Pumping Record
1. Date of I Pumping
ate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
1-1 Other(describe):
4. Effluent Tee Filter present? Ej YesAr No If yes, was it cleaned? El Yes El No
5. Condition of Sysj_er
6. System Pum By:
Name 4�—
W
'vehicleLicenseNumberWind River Environmental_Wind
0 0
7. Location where contents were disposed:
Signat f Hauler
ler
(-----
Dat ---
http://www.mass.gov/d ater/approvals/t5forms.htm#inspect
t6form4.doc-06/03
System Pumping Record-Page 1 of 1