HomeMy WebLinkAbout- Septic Pumping Slip - 190 GRANVILLE LANE 12/10/2018 ---_
Commonwealth of Massachusetts
_.._..
r Ba City/Town of FORTH ANDOVER, MASSA HUSETTS
- 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.
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A. Facility Information
Important: i
When filling out 1• System Location: r'
forms on the /"
computer, use Od-� � nc Ile _.._._..._ . __�.._
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
Address(if different from location)
_ . .., --------------------
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - -- - 2. Quantity Pumped:
Dake Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
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❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste
_._._.__ _.._... rw . �....._.._...._._._ ------------
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6. System Pumped By:
Name Vehicle
Wind River Environmental
------_.__...-_-_
40 S Porter St
Company Bradford, Ma f
7. Location where contents were disposed:
Signature f' a er Date
http://www.mass.gov/dep/waiter/ pprovals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1