HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1469 SALEM STREET 10/21/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
i% 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 f _QI co
com utoter,use Le `
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 � K- --
Name
Address(if different from location) — - -
City/Town -- — ----_-- --- Stat��G�e
Telephone Number
B. Pumping Record
1lU �
1. Date of Pumping pate 2. Quantity Pumped: 'lion
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:
c
6. )ptem Pumped B ----
Name ,/„L/ Vehicle License Number
Wind River Environmental
Company
7. Location where contents re disposed:
:A, 0 �e&
at of Hauler Date
http://www.mass.gov/dep/water/app rcvals/t5forms.htm#inspect
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