HomeMy WebLinkAbout- Septic Pumping Slip - 540 BOXFORD STREET 12/10/2018 Commonwealth of Massachusetts
P City/Town of NORTH9MASSA
CHUSETTS
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 It�formatior� � _
Important: ;
When filling out 1. System Location:
forms on the
computer, use , � 1�'c Y-
anEy the tab key Address ---
to move your North Andover MA 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
._. _._
Name
Address(if different from location)
it /@own Zip Code
y State
Telephone Number
B. Pumping Ripcord _
1. Date of Pumping p g gate 2. Quantity Pumped:
Gallons__.. _�...._._.._
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
[] Other(describe): — ___.._ _____-_----.____
4. Effluent Tee Filter present? dYes No If yes„ was it cleaned? VYes ❑ No
5. Condition of System:
Vo,r- 1 4.ti y o
6. System Pumped By:
m
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
St
� tMao 31�
Sig =Hauler -- C7ate
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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