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Home My WebLink About- Septic Pumping Slip - 546 FOSTER STREET 12/10/2018 Commonwealth of Massachusetts w a 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,Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information rsF i Important: When filling out 1. System Location: forms onthe > computer, r,use 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: Neme Address(if different from location) City/Town State Zip/�, j e a Telephone Number B. Pumping Record 1. bate of Pumping --� / 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) 4 Septic Tank © Tight Tank ❑ Other(describe): -- — _._.. _..._..._._....__...._. --.__. --- 4. Effluent Tee filter present? ❑ Yes [ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition rf System: ___.__....._ '._._._.._ .. ...... _._._— 6. Sys t P tmpey: Name Vehicle License Number Wind River Environmental I. j" ' Company Ipswich, MA. 7. Location where contents were disposed: Signature of Hauler Date http://www.mass,gov/dep/water/approvals/t5forms.htm#insl)ect 1 t5form4.doc-06/03 System Pumping Record-Page 1 of I