HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 496 WINTER STREET 10/21/2019 Commonwealth of Massachusetts
City/Town of NORTH A � a SACHUSETTS
io1 System, Pumping Record -- - ---
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DEF 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 44 U — —
computer,use �•d�
only the tab key Address
to move your North Andover MA 01845
not use the
return
ate Zi
e return P City/Town St Code
use th
Key. 2 System Owner:
fool Z"JOUALA
Name
Address(if different from location)
City/Town State Zip Code
50S Li [ :
Telephone Number
B. Pumping Record
tCl
1. Date of Pumping Da 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) efl"Septic Tank ❑ Tight Tank
❑ Other(describe): -- - - ---
4. Effluent Tee Filter present? ❑ Yes 0"No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: �
6. System Pumped By:
WQf
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: 40 S Porter St
--Bradford, Ma 01 -P
Signature of Hauler Date (978) 374-2382
hftp:/Avww.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•0610Z System Pumping Record•Page 1 of 1