HomeMy WebLinkAboutSeptic Pumping Slip - 148 STONECLEAVE ROAD 8/2/2018 _ Commonwealth of Massachusetts b
- _. City/Town of NORTH! ANDOVER MASSACHUSETTS
' a System Pumping Record
� Yrr` Form 4
veNU
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 Addras _--to move your North Andover MA 01845
cursor-do not __ __
use the return CityrTown State ^ Zip Code
key.
2. System fawner:
___®._ ___
Address(if d(fferent___from__. locatio_ n)
CityrTown Skate
_.
Telephon6 Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped: _.
Gtdl ons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Syst
6. Syste�ped�y:
CC j
I LL
Name vehicle Li erase Numerb ------
Wind River Envi
ronmental
Company 1
7. Location wherocontent ere:�h �l���
CiAd
Signature o4Hule
http://www.mass.gov/dep/water/approvals/t5forms.htmilinspelt,,„ ;
t5form4.doc•06103 System Pumping Record-Page 1 of 1