HomeMy WebLinkAboutSeptic Pumping Slip - 1801-1803 TURNPIKE 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 filing out 1 System Location:
forms on the
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return Cil (Town State Zip Code
key. 2. System Owner:
b
Name
Address(if different from location)
ly,Town SttoZip Code
Telephone Number
B. Pumping Record
00
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) ❑ Septic Tank ❑ Tight Tank
Other(describe):
-�Vl LC
No If yes,was it cleaned? El Yes El No
4. Effluent Tee Filter present? E] Yes
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
TFVVAITS SEPTIC SERVICE
KIMBALL ST.
—BRADEO Q, MA 01835
Signature of Hauler
http://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspec, 978-37�11471
t5form4.doc-06103 System Pumping Record-Page 1 of 1