HomeMy WebLinkAbout- Septic Pumping Slip - 15 FOREST STREET 1/8/2019 Commonwealth of Massachusetts
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City/Town of NORTH AND4VER MASSACHUSETTS
System Pumping Record
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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 �.. _'cv_t C!.
only the tab key Address
to move your North Andover _MA 01845
cursor-do not Cit ft own
use the return Y State Zip Code
key. 2. System Owner:
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Name
Address(if different from location)
CiIyrrown State Zip Code
Telephone Number
B. Pumping Record -
1, Date of Pumping =/71 p 2. QuantityPumped:
DateGallons
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 ❑ No
5. Condition of System:
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6. System Pumped By:
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Name Vehicle License Number _,..._.
Wind River Environmental +
Company
7. Location where contents were disposed:
Signature of Hauler Date
hftp://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect