HomeMy WebLinkAbout- Septic Pumping Slip - 71 JOHNNY CAKE STREET 12/10/2018 Commonwealth of Ma.31sachu.'3etts
a , 6 City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
-mm Form 4
Vim•
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.
i
A. Facility Information
f„o
Important: tr 1
When filling out 1. System Location: J,'
forms on the VA`
computer,use
only the tab key Address
10 move your North Andover MA 01845
cursor-do not __.._..._____.__..., .,.....__.- ----
use the return City/Town State Zip Code
key. 2. System Owner:
b _. _. _
Name
—rrrs° Address(if different from location)
Cit Il"own Stat Zi , o
y
Telophone Number
B. PLIfY'Ip1ng Record
"CA
1, bate of Pumping - -- -04 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Ce.sspool(s) Septic Tank ❑ Tight Tank
F] Other(describe): --_..--------.__---- _..._ ._.._....__..____.__._
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped
Name Vehlcl � _,
icense Number
Wind River Environmental
Company
7. Location where contents were disposed:
_,... _...._._. ...___._...__—__ --._---
Signature of Hauler Date Bradford i
http://www.mass.govldep/water/approvals/t5forms.htm#inspect ,
t5form4.doc•06/03 System Pumping Record-Page 1 of 1