HomeMy WebLinkAbout- Septic Pumping Slip - 314 REA STREET 10/3/2018 Commonwealth of Massachusetts OCIIJ ?018
City/Town of NORTH ANDOVER MASSACHUSEjjg��
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 Locatloxll,
forms on the
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
b t t
Name
Address(if differerii—from-—localion) ---- --
--
diii/Town— --State- - Zip- Cade
7eEephone—Number
B. Pumping Record
1, Date of Pumping k 2. Quantity Pumped: Gallons
- —
3, Type of system: El Cesspool(s) Septic Tank n Tight Tank
El Other(describe):
4. Effluent Tee Filter present?AyEl es No If yes,was it cleaned? Yes El No
5. Condition of System:
6. Syster`12�.=:t
Name
Vehicle License Number
Wind River Environmental
7. Location where contents wer4&Nq
0
Signature of Date
au'
http://www.mass.gov/dep/waterapXpro,vals/t5forms. �ffinsp
t5form4.doc-06103 System Pumping Record-Page 1 of 1