HomeMy WebLinkAbout- Septic Pumping Slip - 78 VEST WAY 12/10/2018 t Commonwealth of Ma(5sachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
_.
System Pumping Exec-ord����
- Form 4
DEP has provided this form for use by local Boards of Health. The System Pumpi1,19,Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
r
Important: �'!;� Y�:�c i v")P f't't
When filling out 1. System Location:
forms on the
computer,use ( �1C.� �r �❑�._.
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:
Name
" Address(if different from location)
City/Town State C 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 F� No
i
5. Condition of System:
6. System Pumped By:
7
Name Vehicle License Number
Wind River Environmental
- �. ii � �
Compan .......y t
7. Location where contents were disposed: 4,D S POrter
St
Bradfq____.....
Signature of Hauler Date
http://www.mass,gov/dep/water/approvals/t5forms.htm#insl)ect
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