HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 185 GREAT POND ROAD 10/21/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDO IL ER, `iASSACHUSETTS
° System Purnpi ng Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumpong Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forme the
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town use the return itY State Zip Code
key. 2. System Owner:
C->
Name
Address(if different from location)
City/Town State -79 62 Z�Co
""1 "S i 8 '
Telephone Number LL
B. Pumping Record
1. Date of Pumping ' ( � t -- 2. Quantity Pumped:
Date yGallons
3. Type of system: ❑ Cesspool(s) -"Septic Tank ❑ Tight Tank
❑ Other(describe): - -
4. Effluent Tee Filter present? ❑ Yes .rNo if yes,was it cleaned? ❑ `des ❑ No
5. Condition of System:
n �
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: I. .P
IPSWich, A4A.
Signature of Hauler Date
'hftp--//�vww.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.dec•06M System Pumping Record-Page 1 of 1