HomeMy WebLinkAboutSeptic Pumping Slip - 93A TURNPIKE STREET 2/20/2018 _ RECF--,IIVED
V E B
OF M,C ft" t ANDOVER
Commonwealth of Massachusetts
City/Town of NORTH) ANDOVER MA$SACH �» �� � � �
. USETTS
System Pumping Record
p 9
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. Sys rt Location:
farms on the
computer,use
only the tab key Address ❑ _�`— _� ' —to move your North Andover
cursor-do not -- — _ MA 01845
use the return City/Yawn State
key.
2. System Own r:
Address if different from location} - -
City/Tawn .....—_... _ .__ .. _... .
Stat i Code _
Telephone Number _
B. Pumping Record
�-D—at 21. Date of Pumping Quantity Pumped: lC
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filterresent?
p ❑ Yes No If yes,was it cleaned? El Yes ❑ No
5. Condition of System: i
6. System Pumped
__ f❑ �, C . ❑.__... __
Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: OtP IC SERVICE
,, JU-��H KIMBALL ST.
973-372-7471
Signature of Hauler pate
http://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect