HomeMy WebLinkAbout- Septic Pumping Slip - 54 TUCKER FARM ROAD 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
onlythe tab key
y Address
to move your V11, t�sE�
North Andover MAC 845
cursor-do not ;
use the return City/Town State Zip Code
key. 2. System Owner:
rab b
--- -
Name
_,._ __-___ _
Address(if different from ._n
location)
-.-__. —_ __._-.m__ °
Cit !YawnState
r
y ---_---- Stat� Zip
Code
Telephone Number
B. pumping Record
1. Date of Pumping eat - 2. Quantity Pumped: -C'
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 System:
� v
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
dW
Signature of Hauler Date
http:f/www.mass.gov/dep/water/approvals/tsforms.htm#inspect
s
t5form4.doc•06/03
System Pumping Record•Page 1 of 1