HomeMy WebLinkAbout- Septic Pumping Slip - 729 BOXFORD STREET 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSET S
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. I
A. Facility Information
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Important:
when filling out 1. System Location:
b
forms on the
computer, use .. 0 r
only the tab key Address
to move your North Andover MA 01845
cursor-do not — _ _........_..._._........_..
use the return City/Town State Zip Code
key. Z System Owner:
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Name
Address(if different from location)
City/Town State( Zip Code
l
Telephone Number
B. Pumping Record
1. Date of Pumping date ? Quantity Pumped: Gallons
1 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe): _..._....._ _. -- __....__.... .... __..
4. Effluent Tee Filter present? ❑ Yes E No If yes, was it cleaned? ❑ Yes ❑ No
5, Condition of System:
6. System Pumped By: a
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
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....... _.........
I
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,htm#Inspect
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