HomeMy WebLinkAboutSeptic Pumping Slip - 700 CHICKERING ROAD 8/2/2018 Commonwealth of Massachut�etts
it /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 filling out 1. System Location:
forms on the
computer.use - dlress�--C'V�'
only the tab key ;
to move your North Andover MA 01845
cursor-do not -——------
use the return City/Town State Zip Code
key. 2. Sy�owner:
&J\(
Name
L—A Address(if different from location)
.0
ltiii6l' -------------
wn State p Code
I 0
97� z'
Telephone Number
B. Pumping Record
1. Date of Pumping 4Dte -67jaa1—<6L 2. Quantity Pumped: 100
Gallons
3. Type of system: El Cesspool(s) R Septic Tank E] Tight Tank
AOther(describe):
4. Effluent Tee Filter present? n Yes No If yes,was it cleaned? n Yes F1 No
5. Condition of Syste
6. System Pumped By-,,—
Vehicle Lice r
Wind River Environmental
7. Location where contents were disposed: 6 ;;>E TIC SERVICE
SOUTH KIMBALL ST.
BRADFORD,
-Signature of—Hauler
http://www.mass.gov/dep/water/approvals/t5forms.htni#inspect gq -1
t5form4.doc-06/03
System Pumping Record-Page 1 of 1