HomeMy WebLinkAbout- Septic Pumping Slip - 20 OLYMPIC LANE 12/10/2018 Commonwealth of Mas achwa etts
City/Town of NORTH ANDOVER MASSACHUSETTS
c;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 ruing out 1. System Location: ` f
forms on the
computer,use
only the tab key Address 1
to move your North Andover MA 01845
cursor-do not _ __..______.._..._ _.__ ____._. . __ _..-- ---..__—_—__—._—.—..._--
use the return City/Town State Zip Code
key. 2. System Owner:
rah
_- '...__..__.._._.._ mac
__._._ Name
Address(if different from tocafion)
.......__ __ ........._
City/Town State Zip Cade
Telephone Number
B. Pumping Record
-
1. Date of Pumping — - 2. Quantity Pumped: — ---
Date Gallons
3. Type of system: T Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other(describe): ._..._ _.._. --------------------- ------
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? Yes No
5. Condition of System:
6. System Pumped By:
,m
Name Ve�l n-se Number
Wind River Environmental
Company
7. Location where contents were disposed ,,
k m
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forrns.htm#inspect
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