HomeMy WebLinkAboutSeptic Pumping Slip - 500 GREAT POND ROAD 7/5/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDQ_ygR
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 Location,
farms onthe
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return Cily]Town
state Zip Code
key,
2. System Owner,
COL.,
Name
Address(if different from location)
State Zip Code
Telephone Number
.................
B. Pumping Record
Date 2. Quantity Pumped;1. Date of Pumping Gallons
3. Type of system: E] Cesspool(s) El Septic Tank El Tight Tank
&—Other(describe):
4. Effluent Tee Filter present? 0 Yes �No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name
Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
STEWARTS SEPTIC SERVICE
"QU IMBALL ST-
BRADFORD MA 01835
Signature of—Hauler
—-q7—"- 7 2-,!W)
http:/Iwww.mass.gov/dep/waterlapprovals/t5forms,htm#inspect
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