HomeMy WebLinkAboutSeptic Pumping Slip - 136 CARLTON LANE 5/21/2018 Commonwealth of Massachus'petts
City/Town of NORTH ANDOVER, MASSACHUSETTS 'SS�
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Recor st
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 Ad;ge
to move your North Andover MA 01845
cursor-do not --
use the return City/Town State Zip Code
key. 2. System Owner:
b
Name
Address(if different from location)
State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) Septic Tank El Tight Tank
n Other(describe):
4. Effluent Tee Filter present? F] Yes Fj. No If yes,was it cleaned? n Yes ❑ No
5. Condition of System:
C)
6. System Pumped By:
-iia-me Vehicle License Number
Wind River Environmental
-Company
7. Location where contents were disposed.,
�i��Jniilr
6re of Hauler --------- 40 8 PorteSt
Dd
hftp://www,mass.gov/dep/Water/approvals/t5forms.htm#inspect f3MdW
(08) 374-2382
t5form4.doc-06/03 System Pumping Record•Page 1 of 1