HomeMy WebLinkAbout- Septic Pumping Slip - 730 WINTER STREET 12/2/2018 Commonwealth of MassachkAsetts
City/Town of NORTH ANDOVER, MASSACHUSETTS �
System Pumping Record�._�
Form 4
DEP has provided this form for use by local Boards of Health. The Systprri,.Fumping (record must
be submitted to the local Board of Health or other approving authority. r
A. Facility Information
Important:
When ftllin out 1. System Location:
g y
forms on the
1 3f
Computer,use tl
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
/M
1
Name
1
Address(if different from location)
----— —-__-------__
City/Town State Zip Code --
Telephone Number
B. Pumping Record --- .----
1. hate of Pumping date — — 2. Quantity Pumped: 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 E] No
5. Condition of System:
6. Systel mp d By: f
" 7 r
Namo Vehicle License Number
Wind Fiver Environm ntal
Company
7. Location where contents were cliiM
WVV
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___. __ �. . -- __..._.___..._ _... _._.._ _..
Signature o f ul. � t
http://www.mass.gov/dep/water/approvaIs/t5forr p c
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
