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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1024 TURNPIKE STREET 10/21/2019 0112 �LN Commonwealth of Massa-husetts City/Town of NORTH ANDOVER, MASSACHUSETTS -- !W; System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pump:ng Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: _ formsmp on the t ©c� . 4 v f'j nil /' n C Lce c computer,use l L� t/ V- C J l C 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: bn Name Address(if different from location) City/Town State t - Zip Code ��� r Telephone Number 1 �'� 1 B. Purnping Record + �`C_� 1. Date of Pumping & tat5( � 2. Quantity Pumped: Gal 0 3. Type of system: ❑ Cesspool(s) Septic Tank El Tight Tank ❑ Other(describe): — 4. Effluent Tee Filter present? ❑ Yes O No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: OV: 6. System Pumped By: Name Vehicle License Number Wind River Environmental Company T-WWT.P 7, Location where contents were disposed: PSWich4 M.A. Signature of Hauler Date hftp:/NAm.mass.gov/dep/ti,vater/appFc.vals/',5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1