HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 78 VEST WAY 10/21/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
4�M
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 V(2 �C A Y
computer, use (_ t
only the tab key Address
to move your North Andover MA 01845
cursor-do not Cityrrown State Zip Code
use the return
key. 2. System Owner:
b C.plj_e�v" CCa
Name
11 Address(if different from location)
City/Town State Zip qd
Telephone Number
B. Pumping Record
1. Date of Pumping Date \ 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ,0'Septic Tank ❑ Tight Tank
❑ Other(describe).
4. Effluent Tee Filter present? ❑ Yes,211No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
0L/
6. System Pumped By:
4-vi �� r2 CU �
Name Vehicle License Number
Wind River Environmental
Company ---- __—
7. Location where contents were disposed.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
I.W.W.T.P.
Ipswicil, MA.
t5form4.doc•06/03 System Pumping Record•Page 1 of 1