HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1155 SALEM STREET 12/4/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
i
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. RECEIVED
A. Facility Information DEC 0 4 2019
Important:
When filling out 1. System Location: TOWN OF NORTH ANDOVER
forme an the i s � � . � HEALTH DEPARTMENT
computer,use _
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:
Name
Address(if different from location)
City/Town State Zip Code
` L
Telephone Number
B. Pumping Record it
1. Date of Pumping Dat 2. Qantity Pumped: Gallons -
3. Type of system: ❑ Cesspool(s) 0--septic Tank ❑ Tight Tank
❑ Other(describe).-
4. Effluent Tee Filter present? ❑ Yes [ 1F No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pum Pd 8yj ,.
f�
�f '54—
Name v Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed.-
Signature of Hauler Date
http://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1