HomeMy WebLinkAboutSeptic Pumping Slip - 328 FOREST STREET 5/21/2018 VC -1D
Commonwealth of Massachusetts
- City/Town of NORTH ANDOVER, MASSACHUSETTS
s
System Pumping Record C \A oggVK
_ 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. Systejxt I cf iQn:
forms on the
computer,use
only the tab key Address
d�
to move your North Andover MA 01845
cursor-do not City/Town/Town _.�
use the return y State Zip Code
key, 2. System caner:
Name
Address(if different from location)
Cit /Town
y State
Telephone Number
B. Pumping Record M
1. Date of Pumping15
2, Quantity Pumped: Gauons
3. Type of system: ❑ Cesspool(s) "Septic Tank ❑ Tight Tank
❑ Other(describe): -- --- -- — — — _ _.
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? Q Yes ❑ No
5. Condit'�°° stem:
6. SystqMPLUtmqpe /,9y:,
Name � —=- ......_-_...�
-�— Vehicle License Number
�
Wind River Environm Ia %
Company ,
0
7. location w was
Signature of Hauler Date
httpJ/www.mass,gov/dep/water/approvals/t5forms.htm#inspect
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