HomeMy WebLinkAboutSeptic Pumping Slip - 325 BERRY STREET 5/21/2018 Commonwealth of Ma,�sachUsetts �^
City/Town of NORTH ANDOVER MASSACHUSETTS 00 2,
R System Pumping Record �40 05
0i :a
Form 4 PpNk
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 tilling out 1. System Location:
forms on the V-> -7 —
computer,use
only the tab key Address - -
to move your North Andover
cursor-do not ---- MA 01$45
use the return City/Town __�� � State Zip Code
-
key,
2. System Owner:
VQ
Name
Address(if different from Iecation)
__
CitylTown State
"t._ Z�ip-f ode
Telephone Number
B. Pumping Record
1. date of Pumping - 2. u —Z-52,Z_)
�a1e Q Quantity Pumped. _.__
Gallons
3. Type of system: ❑ Cesspool(s) J3 Septic Tank Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yesq No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition f Syst m:
6. Sy�tem-pumpe y: — -.
Na� � VeWl le 1-6, se Number
Wind River Environ
Company
7. Location whe c me t
Signature of Hauler pate -_ -- — ---
http://www.mass.gov/dep/water/approvals/t5forms.htm#inst7ect
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