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HomeMy WebLinkAboutSeptic Pumping Slip - 5 CHRISTIAN WAY 1/2/2018 Commonwealth of Massachusetts City/Town of NORTHANDOVERA- NDCVER MA$SACH.�US.E_T..,.TS f a 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. uj A. Facility Information Important, When filling out 1. System Lcation: forms the Computer,use _--� `CA.✓'� _ `� G i6'�I p df I ii �r (i B NrF�_y(di` only the tab key Address to move your North Andover cursor-do not -- — ._ MA 01845 use the return City/Town _. _ State key. Cade 2, System©weer: Zip COD b Name e m Address(if different from location) City/Tpwn _....._. State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping � � 2. 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: _ a C" %2 S Vehicle License Number Wind River Environmental Company —___ _-.___s�_ 7. Location where contents were disposed: Signature of http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect � �y CVC1I IM�9 8 ��i P ,� `„"Wa"✓��ar�M�¢�",ped t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I i