HomeMy WebLinkAboutSeptic Pumping Slip - 415 WINTER STREET 8/2/2018 Commonwealth of Massachusetts
- City/Town of NORTH ANgPNOQR MASSACHUSETTS
System Pumping Record
_
1 ;, = ( Form 4 p
DEP has provided this form for use by local Boards of Health. The System Pumpl must
be submitted to the local Board of Health or other approving authority.
_ '
A. Facility Information _
Important: a
When filling out 1. System Location:
forms on the , y �
computer,use
only the tab key Addr s
to move your Forth Andover MA 01845
cursor-do not -- ----
Cit /Town -
use the return City]Town Zip Code
key, 2. System-Owner:
VQ 1
-Name P e C __ 1-4
' "
A6 Address(if different from location)
City/Yawn
Telephone Number
B. Pumping Record
1. Date of Pumpinga— - -- 2. Quantity Pumped: Gallons
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. Conditiont s'� m.
6. System u i ed B
7 < '~
'j
Name �y 0 "1A", _—� Vehicle License Number
Wind River Environrn 1 C� /
Company
7. Location where Conten ed:
Signature f au - _ — pate
http://www.mass.gov/dep/water/approvals/t5forms.htni#insl)ect
t5forrnit.doc-06103 System Pumping Record-Page 1 of 1