HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 JERAD PLACE 10/21/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER ASSACHUSETTS
System Pumping Record
rY Form 4
M
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 p the
computer,use 1
only the tab key Address to move your North Andover MA 01845
cursor-do not City/Town State
use the return Zip Code
key.
2. System Owner:
b J_ e V I �j
Name - --
iNN Address(if different from location)
CiWTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date r 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present?,,o Yes ❑ No If yes,was it cleaned? ,❑"Yes ❑ No
5. Condition of System:
6. System Pumped By:
('v\P
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: Haverniil V ' T P
- Porter St
a
Signature of Hauler Date
- 2
hftp:lhvww.mass.gov/dep/water/approvalsit5forms.htm#inspect
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