HomeMy WebLinkAbout- Septic Pumping Slip - 80 LACONIA CIRCLE 1/8/2019 rt;
Commonwealth of Massachusetts
4 City/Town of NORTH A.NDOVER, MASSACHUSETTS
System Pumping Record
Farm 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 1
Important:
When filling out 1. System Location:
forms on the computer,use — l.//
4-co
only the tab key Address
to move your North Andover MA 01845
cursor-do not Ctt (town
use the return y State Zip Code
key. 2. System Owner:
VQ b
Name
Address(if different from location)
Citylrown State - Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —t � /4— 2. Quantity Pumped:
hate Gallons .-.—___....._.__.�
3. Type of system: ❑ Cesspool(s) ❑'Septic Tank Q Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ErNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: t
Nama Vehicle License Number
Wind River Environmental
Company _
40 8 Porter St
7. Location where contents were disposed: dford, Ma Q
Signat a of H uler pate
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record*Page 1 of 1