HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 57 COLONIAL AVENUE 10/21/2019 3
Commonwealth of Massachusetts
(� City/Tow n of NORTH ANDOVER9 ASSACHUSETTS��'T 21 -71
201q
- -- System Pumping Record
4� 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 filing out 1. System Location:
forms on the ti 7
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor- not City/Town State Zip Code
use the return
urn P
key. 2. System Owner: ,
:Name
Address(if different from location)
C41Tcun State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Gate — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) KSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
W11-7
6. Systemm Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
7
Si nature of Hauler Date
http://wwvv.mass.gcv/deph;/ater/approvals/t5forms.htm#inspect
Have fm 111 VV VV t ll-
t5form4.doc-06/03 40 S Porter S4 System Pumping Record-Page 1 of 1
Bradford, Ma 01831
(978) 374-2382