HomeMy WebLinkAbout- Septic Pumping Slip - 925 FOREST STREET 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH AND_ a 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:
qA
forms on the
computer,use
only the tab key Address
to move your North Andover MA
cursor-do not
use the return City/Town Slate Zip Code
key' 2. System Owner:
b
Ilk_
°-. _..__.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, bate of Pumping date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [%,Septic Tank ❑ Tight Tank
❑ Other(describe): __._.. .. . _ ...................
4. Effluent Tee Filter present? ❑ Yes IVo 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 disposed:
_---------....... --------............................._-__.a,....-_....__...._.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect 1.W VV ,
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