HomeMy WebLinkAbout- Septic Pumping Slip - 140 MILL ROAD 12/10/2018 Commonwealth of Massachusetts
= City/Town of NORTH TT
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 Cityrfown State Zip Code
key. 2. System Owner:
VQ
lye
Address(if different from location)
I
City/Town State Cam® q Zip Cede
@f. 4✓ w.y My
Telephone Number __....._ _._
B. Pumping Record -
1. Date of Pumping Date mm 2. Quantity Pumped: -_-
Gallons
3. Type of system: Q Cesspool(s) .oI Septic Tank ❑ Tight Tank
F Other(describe):
4. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? ❑ Yes ❑ o
5. Condition of System:
}
6. System Pumped By: 1
Name -- �._..__._
Vehicle License Number
Wind River Environmental
Company
.L. .
D.
7. Location where contents were disposed: North Andover, M A
re of Hauer
S at Date _...
it
http://www,mass.g /d /water/approvals/t5forms.htm#inspect
t5form4.doc•06/03
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