HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 274 BOSTON STREET 10/21/2019 Commonwealth of Massachusetts
W
City/Town of NORTH E DO g ASSACHUSETTS
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 a—1
computer,use TT'
only the tab key Address
to move your North Andover MA 01845
cursor-do not Cltylfown State Zip Code
use the return
key.
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingV
?" Quantity Pupe :oat Gaud
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): — -- ----
4. Effluent Tee Filter present? ❑ Yes rt7l No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
r� �Gz _
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
,wile'! � %
Signature of Hauler Date „ �.
http-,//vvww.mass.gov/dep/Water/approvals/t5forms.htm#inspect r4"N
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