HomeMy WebLinkAbout- Septic Pumping Slip - 138 LACY STREET 12/10/2018 t Commonwealth of Ma.aaachu.3etts
City/Town of NORTH ANDOVE:& MASSACHUSETTS
—.° System Pumping Record
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: �..
forms on the
i
computer,use _ i-C/
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:
4-1 b &",. ..................................
Name
Address(if different from location)
City/Yawn State Zip Codes
Telephone Dumber
B. Pumping Record
D/1 Gallons
�-/ 1 _A��� _.f_�► ..._.._..__.
1. Date of Pumping 2, Quantity Pumped: llons
3. Type of system: ❑ Cesspool(s) Septic Tank OR Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes i No if yes, was it cleaned? ❑ Yes No
5. Condition of System:
6. System Pumped By:
Name Vehicle License N mber
Wind River Environmental
Campany�-� — —
7. Location where contents were disposed:
i
Signature of Hauler Date
http://www.mass.gov/dep/Water/approvaIs/t5forms.htm#inspect
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t5form4.doc 06/03 System Pumping Record-Page 1 of 1