HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 326 FOSTER STREET 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 Pumping Record must
be submitted to the local Board of Health or other approving authority. RECEIVED
A. Facility Information DEC 0 4 2019
Important: TOWN OF NORTH ANDOVER
When filling out 1. System Location:
forms on the � ;� _ HEALTH UEPARTMFNT
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
Name
Address(if different from location)
City/Town State Zip Code —
03 ?2(k 2 1 1(46_t�
Telephone Number
B. Pumping Record
1. Date of Pumping J ® _( S " -- 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Z'/No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: G.L.S•D-
North,Andover, MA.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
