HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10/21/2019 (5) 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 Location:forms on the
computer,use .3 5
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zi Code
use the return P
key. 2. System Owner:
Name - - —
Address(if different from location) --
City/Town State Zip Code
2 7S 3S �
Telephone Number
B. Pumping Record
1. Date of Pumping .. �� ! 2. Quantity Pumped: ,
Date Gallons
3. Type of system: ❑ Cesspool(s) U� Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes KNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
-- --
!Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: I.W.W.T.P.
4., yricb A.
Signature of Hauler Date
hftp://www.rTiass.govidep/water/app,-ovals/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1