HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 JOHNNY CAKE STREET 10/21/2019 ICN Commonwealth of Massachusetts
i CityfTo n of NORTH A DO IE'R, MASSACHUSETTS
e System Purnping 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 Ming out 1. System Location:
forms on the
computer,use J�Il�f V�u2 r
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town/Town
use the return tY State Zip Code
key. 2 System Owner: �(��
Zeal- �'—Ia
Name
Address(if different from location)
City/Town State Zip Code q
Telephone Number
B. Pumping Record
1. Date of Pumping Da�� 2. Quantity Pumped: Gauo
ns
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Other(describe): —
4. Effluent Tee Filter present? ❑ Yes [PVo-_ if yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
IA)6e
Name Vehicle License Number
Wind River Environmental
Company a`11ifl�a {ii N1Df
7. Location where contents were disposed: 40 S Porter St
Bradford, Ma 018S5,
Signature of Hauler Date
http://vvww.rnass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1