HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 RALEIGH TAVERN LANE 10/21/2019 Commonwealth of Massachusetts r)CT 212019,
(� City/Town of NORTH ANDOVER, MASSACHUSETTS
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 t s t l2`0-eI Lrn
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return City/Town State Zip Code
key. 2 system Owner:
b
Name
Address(if different from location) -
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallcns
3. Type of system: ❑ Cesspool(s) ( Septic Tank ❑ Tight Tank
❑ Other(describe): / ----- --
4. Effluent Tee Filter present? ❑ Yes F No If yes,was it cleaned? ❑ `des ❑ No
5. Condition of System:
Wd-
6. System ramped By:
(Kv� "i i
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
I,W'W-T.P
Ipswich, . I
Signatu a of Hauler Date
http:/Avww.mass.gov/dep/waterlapprovals/t5forms.htm#inspect
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