HomeMy WebLinkAbout- Septic Pumping Slip - 496 WINTER STREET 10/3/2018 � Commonwealth of Ma;3sachu,3etts (K "1 M18
City/Town of NORTH ANDC��!E R, Mr4SSACMUSETT w�t���>� � �,r l kr,i�L����si t
,i System Pumping Record i1LA I' t r 14k: k°
Form 4
nEP 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 _ _� f✓I �/�
only the tab key Addres -
to move your North Andover MA 01846
cursor-do not _
use the return City/Town State Zip Code
key.
2. System Owner:
A"` Address(if different from location)
Y State
Telephone umber
B. Pumping Record
1. Date of Pumping Gate 2. Quantity Pumped: Gallons
—
3. Type of system: ❑ Cesspool(s) [fir-°Septic Tank ❑ Tight Tank
❑ Other(describe): _ --
t 4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Conditio� fy '
6. System Ru7ped y:
Name Vehicle License Number ._._-
Wind River Environmental
Company ❑ _ �___
7. Location where contents v t koog2d`.,
Signatur o er � �
http://www.mass.gov/dep/ ter/approvals/t5forms.htm 1
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t5form4.doc•06/03 System Pumping Record•Page 1 of 1