HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 64 NORTH CROSS ROAD 10/21/2019 Commonwealth Of Massachusetts
(� Clty/TOwn of NORTH ANDO 'E , MA5!IACHUSETTS
is 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 t..
computer,use _ 6'4 fV:;r- ( f rzj 3
only the tab key Address
to move your North Andover MA 01845
cur-or-do not /T Cityown State
use the return Zip Code
key. 2. system Owner: 1
'irk IPA myl
Name
Address(if different from location)
City/Town State Zip Code, 7% ma`s
Telephone Number
B. Pumping Record
z.
1. Date of Pumping Date y 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) e( Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes [Z_"No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: _
Name Vehicle License Number _
Wind River Environmental 6 vernm VVW t P
Company � S Peer St
7. Location where contents were disposed: Bradford, Ma 01835
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forrns.htm#inspect
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