HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 CHRISTIAN WAY 12/4/2019 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 Pump in Record must
be submitted to the local Board of Health or other approving authority. RECMVED
A. Facility Information DEC 0 4 2019
Important: TOWN OF NORTH ANDOVER
When filling out 1. System Location:
forms on the l HEALTH DEPARTMENT
computer,use C_i ��4
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
Name
Address(if different from location)
City/Town State Zip Code
7S2,41
Telephone Number
B. Pumping Record
1. Date of Pumping Date Gallons
2. Quay Pumped: G -n ---
fitit Gallns
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 Sysl)ami
6. System Pum ed"'$y;�''
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
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