HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 247A FARNUM STREET 10/21/2019 yC 0V ED
ILI\ Commonwealth of Massachusetts OCT 21 2019
r City/Town of NORTH A DOVER, MASSACHUSE'rTS rR
System Pumping Record
Form 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:
When filling out 1. System Location:
forms on the
computer,use 2`i fY1y'M
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:
�4 b ---—
Name
Address(if different from location)
City/Town State Zip Code
9 2 53 (off'S ZI Z�
Telephone Number
B. Pumping Record
('---z S-
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Type of system: ❑ Cesspool(s) [''Septic Tank ❑ Tight Tank
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes [!(No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6' �`-
6. System Pumped By.-
Name Vehicle License Number
Wind River Environmental
Company
::`vei't'llll VVWTP
7. Location where contents were disposed: Porter St
iradfordf 3..
Signature of Hauler Date
http://w.vw.mass.gov/dep/water/approvals/t5forms.htm#inspect
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