HomeMy WebLinkAboutSeptic Pumping Slip - 40 SALEM STREET 12/19/2017 I%�� cwt
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHIJS�T
System Pumping Record "
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Form 4 � I
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 North Andover
cursor-do not North
use the return City/Town ___ ------ _ _ 0'1$45
key. §tate
2. Syste Own r'
res b �� � 1
Name
Address(if different from location)
City/Tawn _
feleph n�mber
B. Pumping Record
1. Date of Pumping -f- -�r 2. Quantity Pumped:
Dale p Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank
❑ Tight Tank
❑ Other(describe);
4. Effluent Tee Filter present? ❑ Yes rNo If yes, Was it cleaned?
❑ Yes ❑ No
5. Condition of s#em;
f
6, SystemP mpe y;
Name Ve
hicle C_icense
Wind River Environmental
Company ----.—__..._,-.__.__
7. Location Where colisposed;
Signature of Hauler Date --
http://www.Mass-gov/dep/water/approvaIs/t5forms.htm#inspect
t5form4.doc•06/03 J
System Pumping Record•Page t of t