HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 GRAY STREET 10/21/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
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 Loc tion:
forms on the
computer,use (
only the tab key Address
to move your North Andover MA 01845
cursor-do not Ci /Town
use the return State Zip Code
key. 2 System Owner:
bCName
AddressAddress(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) Septic Tank ❑ Tight Tank
❑ Other(describe): -- ---
4. Effluent Tee Filter present? ❑ Yes [�] No If yes, was it cleaned? ❑ Yes �] No
5. Condition of System:
6. System Pumped ��V
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed.
'zol
gnature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#i nspect
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