HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10/21/2019 (3) Commonwealth of Massachusetts
Ci,tyffown of NORTH ANDOVER, MASSACHUSETTS
- : System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pump'Mg Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms to the
computer,use
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:
b rg
Name
a Address(if different from location)
City[Town State Zip Code
G"7 9 `535 +0%I ci l
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 Ef No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
jG; 1?7r2/
Name Vehicle License Number
Wind River Environmental
Company Havorl iild VV WTP
7. Location where contents were disposed: 40 S Porter St
Bradford, hAa 01-8335
L _____ (978) 374�-2382
Signature of Hauler uler � Date
hftp://www.mass.gov/dep/water/approvaM5forms.htm#inspect
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