HomeMy WebLinkAboutSeptic Pumping Slip - 700 SHARPNERS POND ROAD 5/21/2018 P
Commonwealth of Massachusetts
-� City/Town of NORTH ANDOVER MASSACHUSETTS,,,,,,,,�°`� �,�
System Pumping Record
y - 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. System location:
forms on the
computer,use
only the tab key Address —.--
to move your North Andover
cursor-do not ----- —_ — MA 01$45
use the return City/Town --- State Zip Code
key.
2. System Owner:
'
Name —,r
Address(if different from location) — — —`- —�
_..._.___,.—.--- _.._..--__ ..._.... ____.
Ci _..__._ .... _. .._....._ _.-
tyl-rown State .
Zip Code
Telephone Number _--.-_-__.—...-_
B. Plumping Record
1. Date of Pumping L/ I )
p 9 Date —�` Quantity Pumped: Gallon
3. Type of system: ❑ Cesspool(s) [,Septic Tank ❑ Tight Tank
❑ Other(describe): ------- - - W. --_.
4. Effluent Tee Filter present? ❑ Yes [ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
i C' 2
Name — Vehicle License Number
Wind River Environmental
WTp
7. Location where contents were disposed: 40 8 Portgr St
f978)-374-2382--
Signature of Hauler
Date --
--
http://www.mass-gov/dep/water/approvals/t5forms.htni#inspect
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