HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1 LACY STREET 10/21/2019 Commonweaith of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
_ System Pumping Record
�` a< 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 n
computer,
r,use L only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
b
Name T
Address(if different from location) ---
City/Town -- — ----- --+ _-- State Code
Iq
Telephone Number —�
B. Pumping Record I'
1. Date of Pumping "� L 2. Quantity Pumped: �----
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes / No If yes,was it cleaned? ❑ Yes No
5. Condition of System: nOr
6. Sys�e�urftped
Name Vehicle License Number
Wind River Environmental
Company
7. Locati n where contents e disposed:
(,JTP , A A
zLjRi,�V- 161312P(qr
ture of Hauler Date
http,,//www.mass.go /dep/water/apprcvals/t5forms.htm#inspect
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