HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1499 SALEM STREET 10/21/2019 Commonwealth of Massachusetts
Catyffown of NORTH NDO�LE ASSACHUSETTS
Ic, -
- System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pump€ng 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
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not Ci !Town
use the return State Zip Code
key. 2. System Owner:
+ b �ha
Name
Address(if different from location)
Cityrrown State Zip Code
6776Y-ZZ
Telephone Number
B. Pumping Record /
1,. Date of Pumping a l — 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No if yes,was is cleaned? A Yes ❑ No
5. Condition of System:
6. Systern Pumped By:
Name Vehicle License Num er
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
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