HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 248 REA STREET 10/21/2019 Commonwealth of Massavhusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. --he System Pumping Record must
be submitted to the local Board of Health or otter approving authority.
A. Facility Information
Important:
When filling out 1. System Loc tion:
forms on the
computer,use
only the tab key Address - -to move your North Andover MA 01845
cursor-do not City/Town/T
use the return own State Zip Code
key. 2. System Owner:
#m D �i N)
Name -
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Purnping Record
1. Date of Pumping ZO - 2. Quantity Pumped: (
Date Gallons
3. Type of system: ❑ Cesspool(s) 'ETIIS'eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes J2 No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition
/of System:
®K
5. System Pumped By:
AMA S
Name Vehicle License Number
Wind River Environmental
Company
.W.WT.P
7. Location where contents were disposed: Ipswich, MA.
Signature of Hauler Date
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
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