HomeMy WebLinkAbout- Septic Pumping Slip - 255 FOREST STREET 12/10/2018 Commonwealth of Massachusetts
u _ City/Town of NORTH ANDOVER, 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 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 City/Town State Zip Code
key. 2. System Owner:
Name
Addressf d _-_..
"?(
(' different from location)
City/Town State Zip Cod _.._...._
.� r
Telephone Number
B. Pumping Record
1
1. Date of Pumping -._... _...._ _ 2. Quantity Pumped: —..- - __..._.. .... _._
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): _...........
__a.__
4. Effluent Tee Filter present? ❑ Yes ❑o If yes, was it cleaned? ❑ Yes No
I
5. Condition of System:
6. System Pumpe By:
�w f
Name Vehicle�IjVp"I� rVVVVI
Wind River Environmental
_.............._ _. ___................_..__ ���'� P "� er
Company
7. Location where contents were disposed: Bradford, r
..
y
14- 3-
Si a re of Haug Date
http://www.mass.go /de /water/approvals/t5form tm#inspect
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