HomeMy WebLinkAbout- Septic Pumping Slip - 12/10/2018 Commonwealth of Ma.sosachwsetts
-(� City/Town of NORTH A NDOVE R MASSA HUSETTS
S System Pumping Record
sT Farm 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. i
A. Facility Information 1
Important: s i f r .
When filling out 1. System
`�Location:, .
forms on ter,u f _ .... pr✓'�__ /� � J �.C7t�fl`f t I if xP'C i l i ! 1
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:
w
G�—
Name
"2A Address(if different from location)
----------- —__._ _. .____.
City/Town State f Zip Cope.,
------------
Telephone Number
B. Pumping Record
1. Date of Pumping ate
.- - _ 2. Quantity Pumped: moms
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank �'t4 � t <2-,Q _
❑ Other(describe): — _._.... _......_......... .._ ----__--
4. Effluent Tee Filter present? ❑ Yes [ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition oftS� em:
6. System,Ptflpped By
Name — Vehicle Eieelse Nu ber
Wind River Environmental
Company
7. Location where contents w6r, osed:
Si nature of Ha or tA4Y
'
http://www.mass.gov/dep/water/approvaIs/t5forms.htrtf Vect 018 / °
t5form4.doc-06/03 System Pumping Record-Page 1 of 1