HomeMy WebLinkAbout- Septic Pumping Slip - 305 MIDDLETON ROAD 12/10/2018 Commonwealth of Ma;� ach�a. atts
--- - v� City/Town of NORTH ID►tVE;I MASSAHUSETT ` j
SystemPumping F + �;ord .
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 ' s
Important:
When
1' 1 iliac 4 :
forms onfilling out
1. System Location:
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. a 2. Syst m Owner:
�
Name -- _.........._...
g4 Address(if different from location)
City/Town Stat Zip Code
Telephone Number
B. pumping Record
1. Date of Pumping - —� 2. Quantity Pumped: - ---
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ other(describe): ---_
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6. System Pumped Bye_
- _ __._........ _....._.-... __ —
ehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
St
i
Signature of Hauler _ Mr
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect Bradford,
( 7 ) 374-2382
t5form4.doc 06/03 System Pumping Record•Page 1 of 1