HomeMy WebLinkAboutSeptic Pumping Slip - 1444 SALEM STREET 5/21/2018 Commonwealth of Massachusetts � A� p
G r City/Town of NORTH) ANDOVER MASSACHUSETTS
System Pumping Retard
` r Farm 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 InVormation i
Important:
When filling out 1. System Location: /
forms on the "/
computer,use —� -
only the tab key Address y -- ----- —
to move your North And
cursor-do not MA 01845
use the return City/Town State
key.
2. Syste Owner:
- b w
_ c i
Name / S_
- r
Address(if dif/stent from location) "` -------
CitylTown -._.a..__ _._._e... ._._.
State —_
Zip Code
Telephone Number
B. Pumping Record
1. Gate of Pumping �e - 2. Quantity Pumped: - -
Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes P00 If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Sy��//jto
6. System PurC d By:
Name Vehicle License Number
Wind River Environmental 111
Company
7. Location where c nt nts were disposed: � •
—
Blgnature of Haul pate
http://www.mass.gov/dep/water/approvals/t5forms.htm#insl)ect
t5forrn4.doc•05/03 System Pumping Record•Page 1 of 1