HomeMy WebLinkAbout- Septic Pumping Slip - 271 CANDLESTICK ROAD 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH V TT
9
System Pumping Record
t� a
Q 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:
farms the
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computer, use _
only the tab key Address �-
to move your North Andover MA
cursor-donot -y own State q� 45
Cit /T
use the return Zip Code
key. 2. Systeyn Owner:
rob ` .
V ] Le—e
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Name ___..__. __._ _ .--..__.__._..�
_. _. _ __._.. —�-_ — _-_-__.r�crn Address(if different from location)
ikylTown State Zi- ._
J; K;7
Telephone Number
B. Pumping Record - - -
1. Date of Pumping pate- �- -- 2. Quantity Pumped: _.-..- _.
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes14No If yes, was it cleaned? [-1 Yes ❑ No
5. Conditio eystem:
--------... _ 7 __._--___-_-____-__
6. Syste P nped y:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
• 5 y.b
IN LT A
g •ff.d�
Signature of 4H"a—ur Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#lnspect
t5form4.doc•06103
System Pumping Record•Page 1 of 1 ;