HomeMy WebLinkAbout- Septic Pumping Slip - 1 LACY 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 L tion:
forms on the
computer,use na4 .............
only the tab key Address
to move your North Andover MA 01845
cursor-do not
City/Town State Zip Code
use the return
key.
2. System Owner:
b leoco-o e
VQ
E;;1 A Address(if different from location)
-A-
City/Town State
C7
Telephbne Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank El Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? F Yes No If yes, was it cleaned? Fj Yes R No
5. Condition/of 11� stem:
6. System u ped
,
Name Vehicle License Number
Wind River Environmental
Company
7. Location where conte.
Signature f '—r f Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t6form4.doc-06/03 System Pumping Record-Page 1 of 1