HomeMy WebLinkAbout- Septic Pumping Slip - 5 WOODCHUCK LANE 10/4/2018 Commonwealth of Massachusetts 0(3 F 1") 3 ?0 18
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City/Town of NORTH ANDOVER, MASSACHUSET
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
only the tab key Address—
to move your North Andover
cursor-do not MA 01845
use the return City/Town state Zip Code
key.
VQ 2* System 0 b V_V7 Name ----------
Address(if different from—1,cation)
State
Telephone--- Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date �a6o—n-.
3. Type of system: ❑ Cesspool(s) [`Septic Tank 0 Tight Tank
F1 Other(describe):
4. Effluent Tee Filter present? [:1 Yes No If yes, was it cleaned? El Yes El No
5. Condition of Swstem:
E3, System'Qu. ped y:
Name -Y-e-h j—qAk--Z 2n--s'�eNumber
Wind River Environnm�,entall
7. Location wher co nts were,disposed:
;;p
5dgnalure of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#insl)eGt
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