HomeMy WebLinkAboutSeptic Pumping Slip - 39 HAWKINS LANE 5/21/2018 (3) Vge
Commonwealth of Massachusetts �� ��7A
City/Town of NORTH ANDOVER MASSACHUSETT �
.° System Pumping Record
Y p g
t r Form 4
DEP has provided this form for use by focal 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. S stem Location;
forms the ` -
computer,use
only the tab key Address
to move your North Andover MA C1 a45
cursor-do not -
use the return City/Town — State Zip Code
key. 2. System Owner:
e
Name
Address(if different from location)
State ---� ,Zip Code
Telephone Number
B. Pumping Record
Icno
1. Elate of Pumping date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ((Septic Tank ❑ Tight Tank
❑ Other(describe): _
4. Effluent Tee f=ilter present? ❑ Yes A'No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
b�
6. System Pumped By: _
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
I W.W,'.{.F
5ignalure of Hauter Date ,
http://www.mass.gov/dep/water/approvals/t5forms,htm#insl)ect
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