HomeMy WebLinkAbout- Septic Pumping Slip - 500 GREAT POND ROAD 12/10/2018 Commonwealth of Ma:s achwc,ett
City/Town of NORTH ANDOVER� MASSACHUSETTS
System Pumping Record����
Form 4
DEP has provided this form for use by local Boards of Health. The System lumping Record must
be submitted to the local Board of Health or other approving authority. ' I
A. Facility Information --- ;
Important: ��
When filling out 1. System Location: �
forms on the ��computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not _ . -- --
use the return CitylTown State Zip Code
key. ?. System Owner: ,
Name
`❑�°'n Address(if different from location)
City/Town State Zip Code
'' 7 _
Telephone Number
B. Pumping Record
1. Date of Pumping —� /-��----- 2. Quantity Pumped:
Date Gallons
1 Type of system: E] Cesspool(s) ❑ Septic Tank ❑ Tight Tank
9,Other(describe): SC.
4. Effluent Tee Filter present? ❑ Yes -No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were di S sE ARTS SEPTIC SERVICE
`�� U7"Fi KIM�A►�, �� T:
rL
35
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,htm#insI)ec , t°
t5form4.doc-06/03 System Pumping Record-Page 1 of 1