HomeMy WebLinkAbout- Septic Pumping Slip - 18 MARGATE STREET 12/10/2018 Commonwealth of Massachusetts
- - City/Town of NORTH ANDOVER2 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 tilling out 1, System Location: P
forms on the IK
computer,use --- ric, °"d -only the tab key Adss - -
to move your North Andover MA 01845
cursor-do not - —-----
City/Town!Town
use the return y State Zip Code
key. 2. System Owner:
VQ
Name
_--
Address—Cif different from location) ,
CitylTown State Zip Code
1
Telephone Number
B. Pumping Record
- - - yPumped: �r
1. Date of Pumping Date I 2. Quantity Gallons - �._._.a.....-.-
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): — — __ .
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Purnp d By:
C :5710 f
t
Name Vehicle License Num b � � �
Wind River Environmental W T
Company
7. Location where contents were disposed: Bmdford,
u
Sig lure Hauler Date
http://www.mass.gov/diep/w er/approvals/t5forms.htm#inspect
i
t5form4.doc•OW03
System Pumping Record•Page 1 of 1