HomeMy WebLinkAbout- Septic Pumping Slip - 2050 SALEM STREET 2/4/2019 Commonwealth of Massachusetts
_ M6 City/Town of RIORTH ANDOVER, MASSACHUSETTS
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System Pumping Record
±: 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 the
computer,
r,use
only the tab key Address _ 1
to move your North Andover ` � `�
cursor-do not --- _ A 01845
use the return Citylfown — State _ _ Zip Cade _
key.
2. System owner:
Name
Address(if different from
Citylfawn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:Date ._ -
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E( No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6, System Pumped By:
Name —.....__,. _ -- Vehicle License ber _.. _.._._._.
lu
Wind River Environmental
Company ._..._...._.
7. Location where contents were disposed:
40
,
1
Signature of Hauler
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect WFIN q `4
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