HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 OLYMPIC LANE 10/21/2019 _ Commonwealth of Massachusetts
za City/Town of NORTH . DCVER ASSACHUSETTS
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 l 14WN Pi L f1
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
b I y-eV l Sw+r► --
Name
*• Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ` 2. Quantity Pumped: Gallons�
3. Type of system: ❑ Cesspool(s) 2rSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0""No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
I.WW i:R
7. Location where contents were disposed: Ipswich, MA.
Signature of as Date
http://www.mass.govildep/water/approvals/t5forrrs.^tm#inspect
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