HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 OLYMPIC LANE 10/21/2019 Commonwealth of Massachusetts
— (p City/Town of NORTH ANDOVE , MASSACHUSETTS
i° System Pumpir, e r
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 filling out 1. System Location:
forms the 1 O/�
computer,
r r,use 1 7C
only the tab key Address ���-T
to move your North Andover MA 01845
cursor-do not City/Town State Zi Code
use the return p
key. 2 System Owner:
Name
Address(if different from location)
City/Town —— State Zip Code
Telephone Number
B. humping Record
1. gate of PumpingZS^ � 2 Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Xseptic Tank ❑ Tight Tank
Other(describe): —
4. Effluent Tee Filter present? ❑ Yes,k No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name ' Vehicle Licen a t fiber
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/"L5forms.htm#inspect
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