HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 295 CANDLESTICK ROAD 10/21/2019 Commonwealth of McassaChusetts
City/Town of NORTH, ND ER,MASSACHUSETTS
System Pumping Record
Fortn 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 filling out 1. System Location:
forms on the
computer,use cd/,r
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
:04---h
b I y-\
Name
Address(if different from location)
City/Town State Zip Code
P? 9 6ag
Telephone Number'
B. Purnping Record
q-7-
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) pSeptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? F-11 Yes N,No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Ujr)e—tc
6. System Pumped By:
1 ?6
Name VehicleNumber
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
hftp:/ANww.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc-C-6103 System Pumping Record•Page 1 of 1