HomeMy WebLinkAbout- Septic Pumping Slip - 3/4/2019 Commonwealth of Massaci-lusetts
P City/Town of NOR�I I� AN 1 ASSACHl.)SE"I"T;
Systern Pumping Record
-. Fori>n 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:
Whan filling ow 1. System Location:
forms on the nn c �;bG"IP C)� i`IVJi I i�.��P`V1 t911i;i°computotr:r,use e 4
only the tab key address
to move your North Andover MA 018�k5
cursor-do rtot __..._.___y___,_._-.._ _ _ _
use the return Utyffovaistate Zip Code
key.ce__ 2. System Owner:
i
td _ b
Name
— ___..___m,__ _-..._—_—._.,_._
(i€different tram location) -----
CitylTovrn __. ...
Stale Zip__Code.� _...�. .__
TelephoiNumber
B. Punni3ingi Record
1. Date of Pum pin g!.- -.- �
i 9 bate__� _.� __ ._. Quantity Pumped:
�
Gallons
3. Type of system: ❑ Cesspool(s) [?/'Septic Tanis ❑ Tight Tank
[� Other(describe): —___...__—____�__._____
4. Effluent Tee Filter present? [) Yes P ielo a If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Sys ten Purnoed By: J
f4
Vam Vehicle License Number
Wind giver Environmental
___m—pany_ —-----------
'a
7. Location where contents were disposed:
la s—
.w _.
Signature of Ft ufer Date
hftp://www.ryiass.gov/dep/water/approvals/t5forrns.htm#inspect
t5form4.doc-06/03 Ipswich, 1
A.
System Pumping Record•Page 1 of