HomeMy WebLinkAbout- Septic Pumping Slip - 36 BEAVER BROOK ROAD 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTHTT
_ 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 Location:
forms on thecor
r,use
only tab key Address
Y Y
to move your North Andover MA 01845
cursor-do not _
Cit /Town
use the return Y State Zip Code
key. 2. System Owner:
1VQ
Name
_____.__..__ --- --._. _
Address(if different from location) —
i
-._-__ __,. _......._. --------
ity/Tawn
r Code
State Zip C
p
a
Telephone Number V _._.__.
B. Pumping Record
t f t
1. Date of Pumping -Date � -----.� 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) CSe�ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 01<0 If yes, was it cleaned? ❑ Yes No
5. Condition of System:
6. System Pumped By:
1 ^ IL
Name Vehicle License Number
Wind River Environmental
Company ._e...._
7. Location where contents were disposed:
9 Y b 0
North Andover, MA,
fjj�6
Signatur of Mauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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