HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 546 FOSTER STREET 10/21/2019 Commonwealth of Massachusetts
i C€ty/Town of NORTH ANDOYERp A SACHUSETTS
System Purnping Record - - —
Forrn 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 54 ��
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-d not
use the return City/Town State Zip Code
key. 2. System Owner:
b l�
Name
Address(if different from location)
Cityrrown State Zip Code
q7 fs 2 7(.-$5
Telephone Number
B. Pumping Record
1. Date of Pumping Date 7 r 1 9 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [7f Septic Tank ❑ Tight Tank
❑ Other(describe): — —
4. Effluent Tee Filter present? ❑ Yes E2-No If yes,was it cleaned? ❑ Yes [] No
5. Condition of System:
6. System Pumped By:
W _ ?
Name Vehicle License Number
Wind River Environmental '"�y
Company - Haverniii V 4f VVVTP
7. Location where contents were disposed: 40 S Porter St
Rrarl
Ma 0183
t
r� ford, �
__ (978) 374-9-332 _
Signature of Hauler Date
http://www.mass.govi'dep/water/approvals/t5forms.htm#inspect
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