HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 141 CARLTON LANE 10/21/2019 'C"N Cernrnonwealth of Massachusetts
p City/Town of NORTH ANDOVER MASSACHUSETTS
System Purnping Record
r` 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 the l G(� ��Y computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zi Code
use the return P
key. 2. System Owner:
b
Name
Address(if different from location)
City/Town State Zip Code
1?6
Telephone Number
B. Purnping Record
1. Date of Pumping F�( (� 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, Sias it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
hftp:/Mww.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06%03 System Pumli �cord •Page 1 of 1