HomeMy WebLinkAbout- Septic Pumping Slip - 946 OSGOOD STREET 12/10/2018 Commonwealth of Mas achuc:)etts
a City/Town of NORTH AND OVER, MASSACHUSETTS
System Pumping Ric-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. '
1
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
. �„.
computer,use 11 .t _
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:
ah Ib l/1 r Vyd2� 165
✓(�
Name
Address(if different from location)
City/Town State ZipCode
Telephone Number
B. Pumping Rt:cordT--__.___---___.______.
1. Date of Pumping Date 2. Quantity Pumped: Lallans
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes _ hie If yes, was it cleaned? ❑ Yes El No
5. Condition of System:
I
6. System Pumped By:
.w
Name Vehicle License Number
Wind fiver Environmental
Company
7. Location where contents were disposed:
� � - I ;...SEB" 1.0 __._....__ ...
ALL ST-
rnl Sol IT KIMB
Signature of Hauler We RD r MA
http://www.mass.gov/dep/water/approvals/t5forms.htm##insl)ect B AD
g71 -37 -7471 1
t5form4.doc•06103 System Pumping Record-Page 1 of 1