HomeMy WebLinkAboutSeptic Pumping Slip - 2050 SALEM STREET 7/5/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
�r. 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 Location:
forms on the t✓
computer,use Ja !7
only the tab key Address
to move your North Andover MA 01845
cursor-do not Cit !Town
use the return y State Zip Code
key' 2. System Owner: n
Name
Address(if different from location)
CltylTown State 17
Telephone Number
B. Pumping Record
1. Date of Pumping Dat — 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes IrNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Sys m: Ir
6, System P ed 8
Name Vehicle License Number
Wind River Environmental 'jj
Company
7. Location where contents
Signature of He le Date
http://www.mass.gov/dep/water/ap vals/t5form .htm#inspect
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