HomeMy WebLinkAboutSeptic Pumping Slip - 80 LACONIA CIRCLE 12/19/2017 �� v�YY(6 l/v♦
Commonwealth of Massachusetts
s � City/Town of NORTH ANDOVER MASSADHUS
Stem (Pumping Record �ta.
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.
i
A. Facility Information
Important:
When filling out 1. System Lo tion:
farms the
computer,use "� ✓/�G'J/,�� t�ja b�only the the tab key Address
to move your North Andover i
cursor-do not MA
use the return City/Town _ 01$45_Stat—
key. Zip Code
2. Syste weer:
ra4 /
Name
" Address(if different from location)
Cityrfown ---_...____.._ - State —
Code_
Telephone Number --
B. Pumping Record
10�4�_
1. Date of Pumping 13 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspooi(s) Septic Tank
❑ Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? 00 Yes
No
5. Condition?f stem:
6. Syste rnpe gy.
Name Vet7i le Li nse Number
Wind River Environmen al a
Company --'----,—"—_—_._.
I k!I 2
7. Location where con were disposed:
m
,' •=
Sign ur fHauler Cate
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03
system Pumping Record-Page 1 of 1