HomeMy WebLinkAboutSeptic Pumping Slip - 81 PADDOCK LANE 3/19/2018 -Z Commonwealth of Massachusetts
City/Town of NORTH AND
QLELRj-.MASSACHUSETTS
System Pumping Record
V
Form 4
DEP has provided this form for use by local Boards of Health. The System Pum lRec'ordip ROV,
be submitted to the local Board of Health or other approving authority.
A. Facility Information \�E
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your North Andover
cursor-do not MA 01845
use the return City/Town
key, 2. SYsMt _m owner., State Zip Code
b
Name
Td7de�i-s"-(if—differe'-'ri—Ifrem
location)
t�ifow� --------
State Zip Code
Telephone Number
B. Pumping Record
0�40 z 2, IV a
1, Date of Pumping — 2. Quantity Pumped:
Date Gallons
3. Type of system: E] Cesspool(s) A–Septic Tank El Tight Tank
El Other(describe):
4, Effluent Tee Filter present? ELYes El No If yes,was it cleaned? la'Yes El No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Wind River Environmental
Company ----'----------
7. Location where contents were disposed:
Ipswich, MA.
-Signature of Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#insl)ect
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