HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 143 LACY STREET 10/21/2019 Commonwealth of Massachusetts EC'Eff ..
go CitylTown of NORTH AND OVER, ASSACHUSETTS
'; JOT 21 201::
System Pumping Record
Form 4 •`OWN OF NORTH AN'
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 2
computer,use
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:
b SeQ a (hgthy!y
Name
i° Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date I Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Other(describe): - -- -- ---
4. Effluent Tee Filter present? ["Yes 0 No if yes, was it cleaned? �Yes ❑ No
5. Condition of System:
6. System Pumped By:
. g"["" V I I i ql l-(-1
Name Vehicle License Number
Wind River Environmental ,,
Company Haverhill VV VV Ito
7. Location where contents were disposed: 40 S Porter St
Bmlord. Ma DiRar:
(978) 374-2382 _
Signature of HaYler Date
http://www.mass.gcv/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•M03 System Pumping Record.Page 1 of 1