HomeMy WebLinkAbout- Septic Pumping Slip - 274 OLD CART WAY 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
S 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 Syst Location,
forms on the computer, use
only the tab key Address
to move your j
North Andover MA 01845
cursor-do not —------
use the return CityfTown Zip Code
Bey.
2. Syst&R)Ouyvner-
'
VQ b Oww
Name
W(�d Address-(-i-f different—from--1c,caJ:-i[en--)-----
State Z- qc�e
64-iATO —--------
TeIephone Number
B. Pumping Record '741
1. Date of Pumping
qate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [1--S'eptic Tank El Tight Tank
Other(describe): —-------
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes El No
5. Condition of System:
6, 6S y s mp,?d BY:
am _ tuber
Vehicle License Nu
,Wind River Environm ntal
�p
Company �-
7. Location where cont is were di,# 44 01
Signature of Hhr7uler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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