HomeMy WebLinkAboutSeptic Pumping Slip - 143 LACY STREET 7/5/2018 Commonwealth of Massachusetts
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
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Loc on
forms on the C'
computer,use _
only the tab key Address —
io move your North Andover MA 011345
cursor-do not Cit !Town
use the return y State Zip Code
key' 2. System wn
b 3
Name
Address(if different from location)
CilylTown S i C ie
Tel p o e Number G
B. Pumping Record _
� • Z ��� rs
1. Date of Pumping date — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? AYes ❑ No If yes,was it cleaned? - Yes ❑ No
5. Condition of,6
Atem:
tJ
6. System rul ped
Name Vehicle !cense Number
Wind River Environmental
Company
7. Location where content
Signature of auler Date
http://www.mass.gov/dep/water/approvals/t6forms.ht��` Pr
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