HomeMy WebLinkAboutSeptic Pumping Slip - 74 SHERWOOD DRIVE 1/22/2018 Commonwealth of Massachusetts
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City/Town of NORTH ANDOVER MASSACHUSETTS '*+
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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
to move your North Andover
cursor-do not — MA 01845
use the return City/Town State Zip Code
key, 2. System Owner:
VQ b
C
Name
Address(if different from—location)
State.,
Telephone Number
B. Pumping Record
1. Date of Pumping C) 2. Quantity Pumped:
OaVt Gallons
3. Type of system: R Cesspool(s) Septic Tank ❑ Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? El Yes n No
5. Condition of Syst
6. System Puu.�ed By:
C'.
Vehicle License Number
Wind River Environmental
-Company
7. Location where contents were disposed: V
j
q
Signature of Mauler ��� 13
http://www.mass-gov/dep/water/approvals/t5forms,htm#insl)ect
t5form4.doc-06103 System Pumping Record-Page 1 of 1