HomeMy WebLinkAbout- Septic Pumping Slip - 194 BOSTON STREET 10/3/2018 Commonwealth of Ma:-�sachUsetts 0 3 ?0VJ
City/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 J
be submitted to the local Board of Health or other approving authority.
A. Facility Information
3
Important:
When tilling Out 1. System Locatio
forms on the ( >� ❑
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not — — — _.__ _ _ _
Cit !Town
use the return y State Zip Code
key. 2. Syste Owner:
too b _❑ _._____ ___A_ ___
Name
Address(If different from location)
City/Town State ) 3K % Zip ��
Telephone Number
B. Pumping Record
1. Date of Pumping ��t�-�-`'==�---- 2, Quantity Pumped: Gallons
3, Type of system: ❑ Cesspool(s) P" Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syste P)jmpe 6y:
Name 111 Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
36gnature of—au❑r — Date VV ICj _
http://www.mass.gov/dep/water/approvals/t5forrns.htm#inspect ' XTA•
t5form4.doc-06/03
System Pumping Record•Page 1 of 1