HomeMy WebLinkAbout- Septic Pumping Slip - 1187 SALEM STREET 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVERMASSACHUSETTS
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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 the
computer, use
only the tab key Address
to move your North Andover MA 01845
cursor-do not -- --.—
use the return Ci#y/Town
State Zip Code
key. 2. System Owner:
ra8
Name
-- _.__. ____.a_,_ __..__.
Address(if different from location)
Ci#y/Town State Zip Code
Tele ho
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B. Pumping Record _
1. Date of Pumping path ✓ -___ 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: r❑�� ��"
Signature of Hauler
http://www.mass.gov/dep/water/approvals/t5forms.htm##inspect I
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t5form4.doc•06/03 Ott 7* System Pumping Record•Page 1 of 1