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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 975 FOREST STREET 10/21/2019 Coi~ morimealth of Ma-.ssachusetts �o C ty/Town of NORTH ANQO E gMASSACHUSETTS System Purnping 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 only the tab key Address to move your North Andover _ MA 01845 cursor-do not City/Town State Zip Code use the return p key. 2. System Owner: Name Address(if different from location) City/Town State Zip Code s,:;ti12 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 2f No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Wind River Environmental Company 7. Location where contents were disposed: Signature of Hauler Date http:/Avwvv.mass.gov/dep/water/aDprovals/t5forms.htm#inspect avernill VVVV 1 h t5form4.dcc•06103 40 S F'©rter St System Pumping Record•Page 1 of 1 Bradford, Ma 0183 f (978) 374-2382