HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 LACONIA CIRCLE 10/21/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
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:
Men ruing out 1. System Location:
forms on the
computer,use
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:
b MCAI(iC1Lnrjj>
Name
" Address(if different from location)
City/Town State Zip Code
�,7,
Telephone Number
B. Pumping Record
1. Date of Pumping o t� — 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Q"Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [6 Yes 0 No If yes, was it cleaned? of Yes ❑ No
5. Condition of System:
6. System Pumped By.-
Name Vehicle License Number
Wind River Environmental
Company �� t,,,
7. Location where contents were disposed: ��p'ills ��WV 5 �'
40 S POltgr St
(97817-4930
Signature of Hauler Date *' -3 "'
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1