HomeMy WebLinkAboutSeptic Pumping Slip - 5/21/2018 Commonwealth of Massachu',3etts
City/Town of NORTH ANDOVER
_, MASSACHUSETTS
System Pumping Record
W
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 fining out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor_do not Gil !Town __._.
use the return y State Zip Code
key. 2. System Owner,
—_—
Address(if different from location)
City/Town State
Zip Code
— l5'` G*,/
Telephone Number v
B. Pumping Record _
1. Date of Pumpingante 2. Quantity Pumped: -
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
M'Other(describe): - --��
4. Effluent Tee Filter present? ❑ Yes �No If yes,was it cleaned? ❑ Yes EN�No
5. Conditions ofSystem:System: {
6. System Pumped By: l
Name —� Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
�� H KIMBALL BT.
Signature of Hauler �� —..__._ r
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
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t5form4.doc•06/03
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