HomeMy WebLinkAboutSeptic Pumping Slip - 39 HAWKINS LANE 5/21/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOL'ER, MASSA CMUSETT �
.,_�
') ;system Pum in Record
<4 // Form 4 g
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:
forms on the }
computer,use
only the tab key Address — --— --
to move your North Andover
cursor-do not _. _—__ ___.. ___.. MA 01£345
use the return CttyfTown State __ Zip Code - -
key.
2. System Owner: `
b
Name
Address(if different from location)
CitylTown _____....... ...._�..._ State._.__._.__
Zip Code
Telephone Number
B. Pumping Record
I at�� ols- � 0
1. [date of Pumping Date ----- — 2. Quantity Pumped: _
Gallons
3. Type of system: ❑ Cesspool(s) [, Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes A No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: _
Vehicle License Number
Wind River Environmental
Company _ __
7. Location where contents were disposed:
_ 1� i
Signature of Hauler -------......_ Date PSWi h iwtA,
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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