HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 300 FOSTER STREET 10/21/2019 IC CommonweaM of Massachusetts OCT 21 2019
City/Town Of NORTH A DOVER 4ASSACHUSETTS
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
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 kc%V,
Name
Address(if different from location)
Cityrrown State Zip Code
17 ?
Telephone Number
B. Pumping Record
1. Date of Pumping ^ Z— t� 2. Quantity Pumped: S Gta
Date Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [(Yes ❑ No if yes, was i2 cleaned? Yes ❑ No
5. Condition of System:
1.t1G�1�
6. System Pumped By:
Name Vehicle
Wind River Environmentalg�# �` ��d�St
Company 40 S Porter
7. Location where contents were disposed: Bradford, Ma 0183.
(978) 37A_',1 jg*2
Signature of Hauler Date
hftp://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06M System Pumping Record•Page 1 of 1