HomeMy WebLinkAboutSeptic Pumping Slip - 775 FOREST STREET 1/22/2018 Commonwealth of Massachusetts J il
City/Town of NORTF VDC YR M,q ACHUSE
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. Sy em Location: _
forms on the ,1],
computer,use
only the lab key Address
to move your North Andover
cursor-do not ---�___ MA 01845
use the return City/Town --az `-- State
Tip Cade
key,
2. System er:
roti b
Name
r
°�' Address(if different from location) ��
Stale Cod
Telephone r�
B. Pumping Record
1. Date of Pumping Date 2, Quantity Pumped: ---.._
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Q other(describe):
4. Effluent Tee Filter present? ❑ Yes V1 No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
--- __m
6. System Pumped By:
�'C, iU
Wind River Environmental W
Name �� _ hicle Llcenso Number
Company
7. Location where contents were disposed:
Signature of
Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect �W�"'.
-1 p` Ch, ;
t6forenQ.doc•06/03
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