HomeMy WebLinkAbout- Septic Pumping Slip - 131 DUNCAN DRIVE 12/2/2018 Commonwealth of IWIa:,sach Setts
City/Town of NORTH ANDOVE R MASSACHUSETTS
- System Pumping [Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping wycord must
be submitted to the local Board of Health or other approving authority,
A. Facility Information
Important: ' 0I"
When filling out 1. System Location:
forms on the
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. 2. System O er:
Name
---------.
�rrn� Address(if different from location)
City/Towne Zr1-
. de
.._ ..
Telephone Number
B. Pumping Record
1. Date of Pumping _ 2. Quantity Pumped: _ _.w..._..._ ......._. _.
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): _._ __._......._ ..... _.._..... ,_ r __-.-
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company —
7. Location where contents were disposed: Mviloff Mil
r St
Bradford,
Signature of Hauler z e `• t. .
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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