HomeMy WebLinkAbout- Septic Pumping Slip - 163 STONECLEAVE ROAD 12/10/2018 r ,
Commonwealth of Mas achw3etts
- City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Rtec;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.
A. Facility Information _.
Important: -'
When filling out 1. System Location: ,r� `/i�ftl� f
farms on the
Computer,use
lu 5 AQ
,
only the tab key Address
to move your North Andover MA 01845
cursor-do not _..._.__ _,a__---------
use the return City/Town State Zip Code
key. _ 2. System Owner:
b
Name
!" Address(if different from location}
City/Town Stq , Zip Code,
Telephone Number
B. Pimping Record
1. Date of Pumping - --- -- — 2. Quantity Pumped: - —
Date Lallans
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 ❑ No
i
5. Condition of System:
� 4
1
6. System Pumped By:
__. ._w. ........ _........ __.......... _a.. .._.........._. ---
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
I.WWT.P.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,h,tm#inspect
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