HomeMy WebLinkAbout- Septic Pumping Slip - 143 PHEASANT BROOK ROAD 12/10/2018 Commonwealth of Ma.-sachusetts
a � City/Town of NORTH ANDOYER MASSACHUSETTS t
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. ,r
A. Facility Information
When arng out 1. System Location:
forms on
to the
r 9fi
cornpuker,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:
_b__._. : -vrok. �-
Name __._.__.._ _._.___._... ..w._._..._._._.
_.....
r;.xa Address(if different from location)
CitylTown State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping �' - ___._ 2. Quantity Pumped: --.._ __..__ ......__...._.._...w..
Date Gallons
3. Type of system: ❑ Cesspool(s) Xseptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes XNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
,,IG 5
Name Vehicle License Number
Wind River Environmental
Company
7, Location where contents were disposed:
......._._ _ _m.......__._m_.....__a ..........
BT
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forrns.htm#inspect 7 ) 1
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
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