HomeMy WebLinkAbout- Septic Pumping Slip - 3/4/2019 m
CO?1"Ii1'It3n1JtlC;cllth of Mcas sachusetts
Clty/'Town of N ��"I ANDO MAL ► C�il.IS�'i'1"�S.:.:.,.......w..w.�ww,..�.rn�,w �..
-, y tem ul<r i iQig t : lc r l
Form 4
DEP has provided this form for use by los;al Boards of Health. The
be submitted to the laical Board of Health or other approving ��t `F'u¢n�iiiht� Record must
pp g author
A. Facility Won'l ation
Important: Ea
When filling out 1. System Location: �( 1
forms on the
computer,use
only the tab key Address
to move your North Andover cursor-do not MA 018��5
--____._. _._.____,
use the return y State
key. 2. System Owner:
Name _—...__.____—_..._
na '-- Address(if different frorri location)
City/Tom State U / M1 /4 Zip Code
1"elepi7one iVumber
B. Pumping PIOCOM
I. Date of Purn pin _� —._�.--! - U' Q
I 9 •bars.. — _ 2. Quantity Pumped;
Gallons
3. Type 0f system: ❑ Cessp001(s) (. } Septic Tank ❑ Tight Tank
Other(d�scribe): ---- .- 6''-
4. Effluent Tee Filter present? ❑ Yes .-No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle .icense Number
Wind diver Environmental
-._ _
omp�iny
i
7. Location where contents were disposed: STEWARTS SEPTIC SERVICE
_ .._._�_.._.__ _____.._..__._.___.______...._...._______-....... B1��1t FORD, MA01835 1
Signature of Mauler - — ---- ---
http:/Avww.rnass,gov/dep/water/approvals/t5forme,htm##inspect
t5form4.dcc•06103 System Pumping Record-Page 1 of 1
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