HomeMy WebLinkAbout- Septic Pumping Slip - 131 CRICKET LANE 12/10/2018 Commonwealth of Massachusetts
au :: City/Town of NORTH ANDOVER, MASSACHUSETTS
/ System Pumping Record��i
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. V E D
A. Facility Information.____. __— _
Important:
When filling out 1. System Location: Q" i ii,y li Y�yC1V,I Y C �Ywl (.�;i' it^^
forms on the /
t. '
� I (� `� ? I I i C l tLIC'��i�I Chi �i N
computer,use _ /, f' — y4 a'
only the tab key Ad ress
to move your North Andover MA 01845
cursor-do not use the return City/Town -- State Zip Code
key' 2. System ❑w tet; /
V C10—A 11 b---......
Name
-------
Address(if different from location)
City/Town State - N "
Telephone Number
B. Pumping Record
C
_ ,._._... ❑.J� _._ _ .._.
1. Date of Pumping 2. Quantity Pumped: Gallons
1 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 S5vste
6. System Pu d By:
e y
Name r Vehiole Lic nse Number
Wind River Environmental *
Company �r�.,....- _..
7. Location where cunt Is d:PIPE
t
Signature of Hau ,r cot& bate
http://www.mass.gov/dep/water/approvals/t5forms.htrn#'insl) Ct
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t5form4.doc-06/03 System Pumping Record•Page 1 of 1