HomeMy WebLinkAbout- Septic Pumping Slip - 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVE ACHUSETTS
R,-...MASS
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 ocation:—
forms on the
computer, use
only the tab key Address/
to move your North Andover MA 01845
cursor-do not .—------- ——------
use the return CityfTown State Zip Code
key.
2. System Owner:
rob -b � W61
Name
-Address(if different from location)
City/Town State 7, ,rip5ode
Telephone Number
B. Pumping Record
I, Date of Pumping
2. Quantity Pumped.
ate
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
[:1 Other(describe):
4. Effluent Tee Filter present? R Yes No If yes, was it cleaned? F1 Yesll F1 No
5. Condition of Sy 7S
—---------
6. Syst m urn ed By:
Name Vehic'Zeu,
Wind River-En vi iro n ental
Company
7. Location where contents,Were disposed: W
Aj..................
Signature of Hauler Date
http://www.i-nass.gov/dep/water/approvals/t5forms.htm#inspect
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