HomeMy WebLinkAboutSeptic Pumping Slip - 976 TURNPIKE STREET 5/21/2018 MMS
Commonwealth of Massachusetts
CitylTown of NORTH ANDOVER, MAACHUETTS `
System Pumping Record
Form 4
7r�
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. F=acility Information
Important:
When filling out 1. System location:
forms on the �]
computer,use T t 1�1 ti CN iD
only the tab key Address
to move your North Andover MA 01845
cursor-do not _
City/Town _
use the return State Zip Code
key,
2, System Owner:
Name
re:rn Address(if different from location_.
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingDate --_______ 2. Quantity Pumped: - -
Gallons
3, Type of system: ❑ Cesspool(s) Septic Tank M Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 01yes [] No If yes,was it cleaned? ( °Yes ❑ Na
5. Condition of System:
6, System Pumped By:
_
Vehicle License Number ---___
Wind River Environmental
-Company
7, location where contents were disposed:
40S POrtOr
•
http://www.mass,gov/dep/water/approvals/t5forrns.htm#inspect
"978) 374-
a01
t5form4.doc•06/03 System Pumping Record•Page 1 of 1