HomeMy WebLinkAboutSeptic Pumping Slip - 38 FARNUM STREET 5/21/2018 t
Commonwealth of Massachusetts '
City/Town of NORTH ANDOVER1 MASSACHUSETTS
_ System Pumping Record
Y_fl 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 ruing out 1. System Location:
farms onthe
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not Cit /Tgwn
use the return y State Zip Code
key. 2. Syste ner:
rrxS
---- . .
Name
-�--_._.____,_.— ______..,_--..
Address(if different from Igcation)
State
2',,)9-,�- Z 7�-r7
Telephone Number
B. Pumping Record _
1, Date of PumpingQuantity Pumped:
4G,11
3. Type of system: ❑ Cesspool(s) [j- "Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present?lp4es ❑ No If yes,was it cleaned? 1i'Yes ❑ No
5. Condition of System:
..........
6. System' um ed B _
u Vehicle License N �
Name mber
Wind River Envirol /
Compan
G
7, Location whe ��
Signature I Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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