HomeMy WebLinkAboutSeptic Pumping Slip - 79 GRAY STREET 7/5/2018 Commonwealth of Ma:asachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must y
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 1 C-5_,.0 SA-
only the tats key Address
to move your North Andover MA 01845
cursor-do not Cit !Town
use the return y State Zip Code
key. 2. System O er.
b
!Name —
Address(if different from location)
ty! own S
Telephone Number
B. Pumping Record
0C)
1. Date of Pumping a � 2. Quantity Pumped: ��
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑
Other(describe):
4. Effluent Tee f=ilter present? ❑ Yes 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:
Ipswich, MA.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvalslt5forms.htm#insl)ect
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