HomeMy WebLinkAbout- Septic Pumping Slip - 1155 SALEM STREET 12/10/2018 Commonwealth of Massachusetts
- 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 _
Important:
When filling out 1. System Location:
forms On the
computer, use "
t
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:
Qb c, GTC�y1a"C
Name i
Address(if different from location) __.-_____
Tit /Town
Y State _ //Zip Code
Telephone Number
B. Pumping Record
Lallans
1, Bate of Pumping pate --.- -- 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑] Other(describe):
4. Effluent Tee Filter present? ❑ Yes [X No If yes, was it cleaned? ❑ Yes ❑J No
5. Condition of System: i
6. System Pumped By:
i 1411
Name Vehicle License Number
Wind River Environmental
—
Company I
7. Location where contents were disposed: 1
Signature of Hauler Date ,
http://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect
t5form4.doc•06/03
Syst 4.Pumping Record• Page'I of 1
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