HomeMy WebLinkAboutSeptic Pumping Slip - 96 LOST POND LANE 5/21/2018 s Commonwealth of Massachusetts
,.. .. City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
m
„ 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: /1
When tilling out 1. System Lacat'o
forms on the
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not ___.-_.d.__.. _..._............----.---_._......---..__.___-_.__. _.
use the return City/Tow' State Zip Code
key, 2. Syste o ner:
r�
a b � ,�/
Name
Address(if different from location) –�— --- � –
Clty/Town _. State ... - _.. ._ _..
_.f � _ �'��Zip„twgcle�
Telephone Number _
B. Pumping Record
1, Date of Pumping ante - ----- 2. Quantity Pumped: Gallons
3, Type of system: ❑ Cesspool(s) R"Septic Tank ❑ Tight Tank
❑ other(describe):
4, Effluent Tee Filter present? ❑ Yes q,
No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of S stem:
5. Syste P mped y: <
Name / Vehicle License Number
Wind over Environmental
Company
7. Location where contents e
Signature of Haerg le
http://www,mass.gov/dep/water/approvals/t5forms.h in ---specC-- `-
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