HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 111 BROOKVIEW DRIVE 10/21/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumpng 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
computer,use 11 i �,Zi/1�ftttJr —.
only the tab key Add—�~
to move your North Andover ;VIA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:or h
1
b
Name
Address(if different from location) —
City/Town State Zip Code
q7% Sy-)q `s1 /
Telephone Number
B. Pumping Record �j 8
1. Date of Pumping Z-q 2. Quantity Pumped: 1ef
Date Gallons
3. Type of system: ❑ Cesspocl(s) ❑ otic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes?10'No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
rtJ C�3 - y
Name Vehicle License Number
Wind River Environmental
Company HavermiI vv vv , 6-
7. Location where contents were disposed: 40 S Porter St
Bradford, Ma 0183
(9781374-2382
Si nature of Hauler Date
httID-./hvww.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1