HomeMy WebLinkAboutSeptic Pumping Slip - 93 SUGARCANE LANE 7/5/2018 Commonwealth of Massachusetts
rs
City/Town of NORTH ANDOVERI MASSACHUSETTS
_ System Pumping Record
Form 4
DEP has provided this form for use by local Hoards 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:
farms (the
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not Cil (Town
use the return y Slate Zip Code
key.
2. SysfemPwner:
game
Address(if different from location)
CitylTown State — Zip Code460 1 `
C
Telephone Number
B. Pumping Record _
1. Date of Pumping � ��2. Quantity Pumped:
D
ate Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ^No If yes,was it cleaned? ❑ Yes ❑ No
5. Conditior)-Qf stem:
6. Syste P mpe By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contgAs were disposed:
vicb TVi a
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Signalure aider hate "
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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