HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 235 RALEIGH TAVERN LANE 10/21/2019 .3
Commonwealth of Massachusetts OCT 2 12019
(/p City/Town of NORTH AND OVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumpng 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 oz a57------ALI
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return Cityrrown State Zip Code
key.
2. System Ow per:
b
Name
Address(if different from location)
City/Town State Zip Code
978-691- /0913
Telephone Number
B. Pumping Record
1. Date of Pumping 2 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
F1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? Ej Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were dis,00sed: 40 S Porter St
Bradford, Ma 0183'-
978) 174_1,�ij
Signature of Hauler Date
http:/Avww.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06103 System Pumping Record-Page 1 of 1