HomeMy WebLinkAboutSeptic Pumping Slip - 315 SOUTH BRADFORD STREET 5/21/2018 Commonwealth of Massachusetts
City/Town of FORTH ANDO'V'ER, MASSACHUSETTS
System Pumping Rekord
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.
l
A. f=acility information r
Important:
When filling out 1. System Location:
farms the
computer,use _❑� .���� � ��-�� '`—��.
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zi Code
use the return p
key, 2. ,System Owner:
�s b _
Name
Address(if different from location)
City/Town Stale Zip Coe
Telephone Number
B. Plumping Record
1. cK7Date of Pumping 6-Ift„C�i , Quantity Pumped:ate Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
2�—Qther(describe): -
4. Effluent Tee Filter present? [j Yes G6,,No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped B
Name Vehicle License Number
Wind on
River Environmental
Company___ _. STEVVAH"i S SEPTIC SERVICE
7. Location where contents were disposed58 SOUTH KIMBALL ST.
BRADFORD, MA 01835
978-37�-7471
Signature of Hauler m� _. _.� Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
15form4.doc•06/03
System Pumping Record•Page 1 of 1