HomeMy WebLinkAboutSeptic Pumping Slip - 445 FOREST STREET 5/21/2018 REC�EiVED
'� l
Commonwealth of Massachusetts mw '
9' STOW,,()F tjor�T14 ANDOVER' City/Town of NORTH ANDOVER, MASSACHUSETTS
-Ar
System Pumping Record DEP �TM.
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
co ILI
computer,use
only the tab key Wddress
to move Your North Andover MA 01845
cursor-do not
use the return City/Town Slate Zip Code
key. 2. System Owner:
b
It
Name
Address(if different from location)
biiyd To-w—n -- —Zip--C d-
L
Telephone Number
B. Pumping Record
1. Date of Pumping N 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) Septic Tank El Tight Tank
E] Other(describe):
4. Effluent Tee Filter present? [ Yes M No If yes,was it cleaned? [ Yes [:1 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 ��� 0
Dat
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect North Andover, MA.
t5form4.doc-06103
System Purnping Record-Page 1 of 1