HomeMy WebLinkAboutSeptic Pumping Slip - 650 FOREST STREET 5/21/2018 Commonwealth of Massachusetts
- , City/Town of NORTH ANDOVER MASSACHUSET1V#rm
System Pumping Record 2
Form 4
DEP has provided this form for use by local Boards of Health. The System Pump ng 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 the �
computer,use ..,0 N 1-0 `.�___...-_ .�1._.m`
only the tab key Address
to move your North Andover _MA 01845
cursor-do not Cit !Yawn _ —__
use the return City/Town Zip Cade
key.
2. System Owner:
rQ b
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping )S o j )O — 2ate . Quantity Pumped: Ilan
3. Type of system: ❑ Cesspool(s) r Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 6 No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: _
Name Vehicle License Number - +
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Data,Worth
A � MA.http:/!www.mass.govJdepJwater/approvals/t5forms.htm#inspect �PyI j ["lei
t5form4.doc-06103 System Pumping Record-Page 1 of 1