HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 10/21/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
c-- 1 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 Locati n:
forms on the ^� t % (0 4V—'VD
computer,use �J J I20'l IjJ
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:
Name
Address(if different from location) ---
City/Town State Zip Code
Telephone Number
B. Pumping Record /
1. Date of Pumping 2. Quantity Pumped:
Date 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:
Oa10
6. Syste e y: �4 7-341 -
Name Vehicle License Number
Wind River Environmental
Company
7. Location txTeMs_were disposed
Si`na of auler ---
Date —
http://www.mass.gov/dep/water/apprcvalslt5farms.him#inspect
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