HomeMy WebLinkAbout- Septic Pumping Slip - 37 SCOTT CIRCLE 1/8/2019 Commonwealth of Massachusetts
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City/Town of NORTH ANDOVER MASS ACHUSETTS
System Pumping Record
Form 4
_ 1
QEP 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 t
f
Important:
When filling out 1. System Location:
forms the ✓
computer,use _ M ?�
only the tab key Address
to move your North Andover _MA 01845
cursor-do not Cit (fawn _ —
use the return y state Zip Code
key. 2. System Owner:
Q b
Name
Address(if different from location)
Cityffawn _ State Zip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping poi 2. Quantity Pumped: -1 -
Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe): — -- —........ .... __..
4. Effluent Tee Filter present? ❑ Yes dNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Syste :
6. System Pu ed B
___ W ✓ _.__ '7(2
Name Vehicle L se Number
Wind River Environmental v r"Ill vvwftj
Company 40 8 Portor
7. Location where contents were disposed: ford,
Ma 01835
Signature of Ma er pat
http://www.mass.gov/dep/water/a provals/t5forms.htm#inspect
t5form4.doc-06103 system humping Record-Page 1 of 1