HomeMy WebLinkAboutSeptic Pumping Slip - 236 SUMMER STREET 7/5/2018 mavernot VV\NTP
�L\ Commonwealth of Massachusetts 40 S Porter St
City/Town of NORTH ANDOVER, MASSACHU604M"1836
System Pumping Record '97 -2382
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 I System Location:
forms onthe
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return CitylTown State Zip Code
key.
2. System 0 ner:
va�.=All b 1(00
Name
Address(if different from location)
City/Town Stat
Zi Code
Telephone Number
B. Pumping Record
1 Date of Pumping2. Quantity Pumped:
ODate - • Gallons
3. Type of system: El Cesspool(s) (Septic Tank ❑ Tight Tank
El Other(describe):
4. Effluent Tee Filter present? E] Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
C,
6. System Pumped By:
s-6
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc-06103 System Pumping Record-Page 1 of 1