HomeMy WebLinkAboutSeptic Pumping Slip - 1801 TURNPIKE STREET 4/3/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
/ Form 4 p
DEP has provided this form for use by local Boards of Health. The System P ,Record must
be submitted to the local Board of Health or other approving authority. ."" i,�
n�
IVED
A. Facility InformationfuR d 01 '
Important:
When filling out 1. System Location: TOWN U'LCL'°C I ANDO ER
forms on the - I lL�� W"H ERARTME' NT
computer,use _��t 1 ti Y� �C (�-
only the tab key Address ` M - ---_.
to move your North Andover
cursor-do not _ ._ ._. �____.____�_ ______ MA 01845
use the return City/Town State -
Zip Code
key.
2. System owner:
IL Ar Name
""`° Address(if different from location)—'_.�.
State
Zi Code
Telephone Number -
B. Pumping Record
' . :dot _
1. Date of Pumping Date ��� Quantity Pumped; - —..---.
Gallons
3. Type of system; ❑ Cesspool(s) ,Septic Tank .Tight Tank
Other(describe): i
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: r
16 J C,
License Number
Wind River Environmental
Company
7. Location where contents were disposed: S,"E,S.D.
Saim
Date "� t
hUp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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