HomeMy WebLinkAbout- Septic Pumping Slip - 145 CARLTON LANE 12/10/2018 Commonwealth of Ma:s achuts)etts
City/Town of NORTH ANDOVER MASSA HUSETTS
Y° Systern Plurnping Record�._
Form 4
DEP has provided this form for use by local Boards of Health. The System F,"umping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
ILIA
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 Owner:
s _ b ..._
Name
r" Address(if different from location)
City/Town Stat � Zip Code
U& L . Lo -
Telephone Number
B.4Pumping Record
1. [late of Pumping ❑ � - 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
n Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
cico
6. System Pumped BY: � - • _� .._._�:
—_ ._.. __ ......._._ ...._......__. _......__ _.._......_...._
Name Vehicle license Nurrrber
Wind River Environmental
Company
7. Location where contents were disposed: P yeryy iii 'MV-1
40 S Porter St
Signature of Hauler [late Bradford,,
http://www.mass.gov/dep/water/approvals/t5forms.htrn#inspect ( 7 ) 7 -
2-382
t5form4.doc-06/03 System Pumping Record-Page 1 of 1