HomeMy WebLinkAboutSeptic Pumping Slip - 500 GREAT POND ROAD 2/20/2018 RECEIVED
Commonwealth of Massachusetts
City/Town of fr ORTH ANJDO R, MASSACHUSETTS �1 � � ���18
System Pumping Record 'TOWN OFNORTH ANDOVER
- :_ Foram 4 HEALTH DEPARTMENT
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. S r§tem Location:
farms on the ("
computer,use - r
only the tab key Address _ ir.
to move your North Andover
cursor-do not -- _..____. ___ MA 01845
use the return ci(y/Town _—� State
Zip code
key,
2. System Owner: /
Name
1
i
Slate -_. _.. t
Zip co Ike Cr
Telephone Number —�------
B. Pumping Record
1. Date of Pumping } =p,
p g Da a __ 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic 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:
� -caw. C
Name _ Vehicle License Number
Wind River Environmental
company _.._.._� STEWARTS SEPTIC SERVICE
7. Location where contents were disposed: 58 SOUTH KIMBALL ST.
BRADFORD, MA 01835
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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t5form4,doc•08103
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System Pumping Record•Page 1 of 1
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