HomeMy WebLinkAbout- Septic Pumping Slip - 1312 SALEM STREET 10/3/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS 0 3 H18
n System Pumping Record iiki °i �� r iMiiiii � i
Form 4 a fl A i i ii uD�-7�7 WENT
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. 1
A. Facility Information
Important:
When filling out 1. System Location:
forms on the �,
computer,use _ ❑ ,1
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town frown
use the return y State Zip Code
key. 2. System Owner:
Name
6 Address(if different from location)
City/Town _ -. —St at"e
Telephone Number
B. Pumping Record
1. Date of Pumping Date -J — 2. Quantity Pumped: —
Galfons
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 Sym:
6, System Pined y:
/r/r1
Name Vehicle License Number
Wind River Envirorm
Company i�� �
7. Location where�?S �iiid:
_
.5ignatur o aver — palb
http://www,mass.govldep/water/approvals/t5forms.htm#inspect
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t5form4.doc•06103 System Pumping Record-Page t of t 4