HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 PENNI LANE 10/21/2019 COrnrrlorwealth of Massachusetts
a City/Town of NORTH, A DOVE , MASSACHUSETTS
System Pumping Record
.>� Form 4
M
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 on the
computer,use he'I
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
Name A'
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Purnped: Gallons
3. Type of system: ❑ Cesspool(s) ErSeptic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes [j No If yes,was it cleaned? ❑ Yes ❑'No
5. Condition of System: ✓` �
6. System Pumped By:
41V�''I'S" (_44rd
Name I Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: Haverhll vY vv I I-
40 S Porter St
� 1---� Bradford, Ma 01835
Signature of Hauler Date —_
http://www.mass.gc.v/dep/water/a,oprovals/t5forms.htm#inspect
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