HomeMy WebLinkAbout- Septic Pumping Slip - 740 FOREST STREET 1/8/2019 . �ma
Commonwealth of Massachusetts
t City/Town of NORTH ANDOVER, MASSACHUSETTS
1 System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must 1
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
farms on the
computer,use
only the tab key Addressto move your North Andover MA 01845
cursor-do not _.._
use the return Cityfrown State Zip Code
key. 2, System owner:
Name
Address(if different from location)
City/Town State Zip Code _
Telephone Number
B. Pumping Record
1. Date of Pumping p g Qa ��_ 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) U)Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �"o If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition off System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
-� 6A-11AR0 ,
Signature of Hauler ����� Date
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
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