HomeMy WebLinkAbout- Septic Pumping Slip - 1/8/2019 m .
Commonwealth of Massachusetts
u City/Town of NORTH ANDOVER MASSACHUSETTS
_ System Pumping Record
a
�. Form 4
DBP 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 r pp
computer,use TL hn fy
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:
ra3 bi
Name
` Address(if different from location) -----.--.-_.._
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate 2. Quantity Pumped: --
Gallons
3. Type of system: ❑ /�?Cesspool(s) El Septic Tank ❑ Tight Tank
l
❑ Other(describe); ()-t --- _.._....__
4. Effluent Tee Filter present? ❑ Yes U/No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
br •.
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were dispo EWARTS SEPTIC SERVICE
58 SOUTH KIMBALL;T.
Bt�C[3Ft�RDa M
97-8-372-74�
Signature of Hauler pate
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
i
t5form4.doc•06/03
System Pumping Record•Page 1 of 1