HomeMy WebLinkAbout- Septic Pumping Slip - 34 WILLOW RIDGE ROAD 12/10/2018 Commonwealth of Ma:asachwSetts
City/Town of NORTH ANDC,VER MASSACHUSETTS j
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: 8 t grrt�p,y(;°i i 4tJV�(�4 f i fLt)Vi.R
forms on the
computer,use ?A
_� �
only the tab key Address 11
to move your North Andover MA 01845
cursor-do not _ __..._.m _.._..__.._
use the return City/Town .State Zip Code
key. _ 2. System Owner:.
V\--
Name
° Address(if different from location)
City/Town State Zip ode
Telephone Number
B. Pimping Record---____
2
Date _..
1. Date of Pumping _ . Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes 1K No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Veh c e License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler_._. ------_......__.___�_ e _ „
http://www.mass.gov/dep/water/approvals/t5forrrls.htrn#insl ram.
t5form4.doc•06/03 System Pumping Record•Page f of 1