HomeMy WebLinkAbout- Septic Pumping Slip - 25 JERAD PLACE 12/10/2018 Commonwealth of Massachusetts
W 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 - rt
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 Cityfrown State Zip Code
key.
2. Sy/stem Owner:
r b ! J_._.....___
6
Name
Address�(ifint from location)
e2ve
!Yawn _.w. .—._ �,--..._
y �_._
Cit - State Zip Code
Telephone Number
B. Pumping Record _ _.._..
___ �. Y p Gall '
1. Date of Pumping
p g Date 2. Quantity Pumped:
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 0 a
5. Condition of system:
G/ .
6. System Pumped By,
Name!__ 6 ( .._
Vehicle License Number
Wind River Environmental ��_-
Company
7. Location where contents were disposed: 40 8 Porter St
_ 3radford, Ma 01835
a
Sig of Haul r Date
http://www.mass,g de ater/approvals/t ms.htm#inspect
t5fori,n4.doc•06/03 System Pumping Record•Page 1 of 1