HomeMy WebLinkAbout- Septic Pumping Slip - 1300 SALEM STREET 12/10/2018 L\ Commonwealth of Massachusetts
City/Town of NORTH ANDOVER,
System u in or
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: /1
When filling out 1. Syst Loc Ion: r fiJ r
forms on the
s
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not __._ __ _____ _.__.__.---.'-------___.—.._----------.--_ -----_.___- ----__-._.
use the return Clty/Town State Zip Code
key. 2. System Own r:
b - �
Name
_ Address(if different from location)
City/Town State ip Code
7f�
- -- �_ _ .........
Telephone Number
B. Pumping Record
1. Date of Pumping V 2. Quantity Pumped: lo
Date Gallons
3. Type of system: ❑ 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 S s m:
6. Syste P m=pB
Name Vehicle License Number
Wind River Environment I
Company40
7. Location where contents e d
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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t5form4.doc-06/03 System Pumping Record•Page 1 of 1