HomeMy WebLinkAboutSeptic Pumping Slip - 97 LOST POND LANE 8/2/2018 Commonwealth of Massachu,,3etts
City/Town of NORTH ANDOVE
'R
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, i
A. Facility information
Important:
When filling out 1 Sys i Loc40ion:
forms on[he
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return City/Town State Tip Code
key.
2. Syster Owner-
o.b (DUN-e
Address(if ji—ffereni—fromi-o—cation) ——City/Town State -Z—--------
617 7 Zip C
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped: -da—lions
3. Type of system: ❑ Cesspool(s) Septic Tank E] Tight Tank
E] Other(describe):
4. Effluent Tee Filter present?/rfl Yes E] No If yes,was it cleaned? 2�Yes F1 No
A
5. Condition of System:
A)
6. System Pur edName IN:
-Vehicle Lic nse Number
Wind River Environmental
7. Location where contents were disposed:
Signature of Hauleiy Date
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect MWIP.
Ipswich, MA.
t5form4.doc-06/03System Pumping Record-Page 1 of 1