HomeMy WebLinkAbout- Septic Pumping Slip - 80 LACONIA CIRCLE 12/10/2018 Commonwealth of Massachusetts
r 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.
t
A. Facility Information —.___..._
Important:
When filling out 1. System Location:
forms on the
comp use
Y the tab key Address
y --- _._...__......
onl
to move your North Andover MA 01845
cursor-do not
use the return
City/Town State Zip Code _...._ ....._.._._____.._.__
key. 2. Sy(st.,ee.,.'m Owner:
V bst �.4l ".
`ti"..F..
Name
Address(if different from location)
City/Town State Zip Code
C ` � JLI � .
_....._.._......._.._......._._........ ----------- ---
Telephone Number
B. humping Record
1. Date of Pumping Date V 2. Quantity Pumped: Gallons ..._...___
3. Type of system: ❑ Cesspool(s) `❑Septic Tank ❑ Tight Tank
Q Other (describe): _ .. _......_ -_ _._.__.__
4. Effluent Tee Filter present? ❑ Yes ❑No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
r
Name Vehicle License Number
_Wind River Environmental
._.............._ ..._ _.__.____
Company �N �/
7. Location when werdl :
❑-- _ . la_ ►. _.__ .._.__ .
Signature of Haul Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record• Page 1 of 1