HomeMy WebLinkAbout- Septic Pumping Slip - 122 BOXFORD 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
5 1
Important: '
When filling out 1. System Location:
forms on the
r
computer,use
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:
m4 b {1 4 C
-------------- --
d Address(if different from location)
i
Cit /Town State >V gq(1c ode
y / p
Telephone Number
B. Pumping Record
1. bate of Pumping 2. Quantity Pumped: -� - - --
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): __�_....__ _m__,.__...._-.------
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
i
5, System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
M d.E
t5form4.doc•06/03 swi h�6 &, umping Record•Page 1 of 1