HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10/21/2019 (7) Commonwealth of Massachusetts
City/Town of NORTH ANDOVER. MASSACHUSETTS
System Pumping Record
,r
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 Ming out 1. System Location:
forms on the
computer,use ' `.! e}
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town use the return State Zip Code
key. 2. System Owner:
Name
° Address(if different from location)
City/Town — -- State —— Zip Code
Telephone Number
B. Pumping Record
t GIG
1. gate of Pumping Date 2. Quantity Pumped: 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:
6. System Pumped By:
11--j
Name Vehicle License Number
Wind River Environmental �� p
Company H��W111 yVTr"
7. Location where contents-were disposed: 40 S Porter St
Bradford, Ma 01835
s __ (978) 374-2382
Signature of Hauler —� Date
http://v,rww.rnass.gov/'dep/Water/approvals/t5forms.htm#inspect
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