HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 122 FARNUM 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�lon:
forms the I•7 ( �
computer,
r,use C '1'�tV�
only the tab key Address to move your North Andover __ MA_ 01845
cursor-do not __ ___
use the return City/Town State Zip Code
key.
2. Systpfn Owner:
vII b P_Z�)l44!-
Name
Address(if different from location) --
City/Town --- ----- -------- --- State --- -- - Zip Code
Telephone Number
B. Pumping Record
()CDC)
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 t No If yes, was it cleaned? ❑ Yes No
5. Condition of System:
6. System Pumggd�
Name Vehicle License Number
Wind River Environmental
Company
7. Locat' n 99ELU
Date —�
http://www.mass.gov/dep/water/apprcvals/t5forms.htm#inspect
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