HomeMy WebLinkAboutSeptic Pumping Slip - 141 REA STREET 5/21/2018 Commonwealth of Massachusetts VE I
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record "
Form 4 �
i
DEP has provided this form for use by local Hoards 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,use
only the tab key Address --------__�___�
to move your North Andover MA 01845
cursor-do not City/Town!Town — —_ ------,---_
use the return Y State Zip Code
key. 2. Sym Owner:
ns
bay(
Name — ___ _______.-................m._.
rr n Address if different from location)'-- --. —_
CitylTown Stag �p�d�
Telephone Number
B. Pumping Record
1. mate of Pumpingt' ►f` t �—y— 2. Quantity Pumped: 4 )
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): -- --- — __
4. Effluent Tee Filter present? ❑ Yes [ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
r
6. System Pumped BY
Name Vehicle License Number
Wind River Environmental
Company
7, Location where contents were disposed: I(AW [i"W
_ 3radford, (l1
Signature of Haule '97878374-2382 a
http://www.mass.gov/dep/water/approvals/t5forms.htm#insl)ect � � "" 7
t5form4.doc•06103 System Pumping Record•Page 1 of 1
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