HomeMy WebLinkAboutSeptic Pumping Slip - 35 MARIAN DRIVE 5/21/2018 Commonwealth of Massachusetts qty
a7 _ City/Town of NORTH ANDOVER, MA.SSACHUSETT, ` �"?
System Pumping Record
�7 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. System Location:
forms on the
computer,useonly(tie tab key Addressto move your North Andover
cursor-do not _ MA 01845
use the return City/Town __ �_ State Zip Code
key. 2. System Ow
_b__
Address(if different from location)
I
i
state
-90/.�
Telephone Number
B. Pumping Record
1. Date of Pumping p g Hha _ —_—_ 2, Quantity Pumped:
Gallons=
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank Q Tight Tank
® Other(describe):
4. Effluent Tee Filter present?"Yes ❑ No If yes,was it cleaned? Yes ❑ No
5. Condition o€ y tem:
6. System u ed
Name _ 4VeWcicense
Wind River Environment I
7. Location where contents w re disposed: !
IN�,�C
WIC
Signature of r Dale
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc 06!03 System Pumping Record-Page 1 of 1