HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 645 SHARPNERS POND ROAD 12/4/2019 Commonwealth of Massachusetts
n W_p City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
t� 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.
RECEiX/En
A. Facility Information Important: DEC
C 0 4 2019
When filling out 1. System Location:
forms on the G `~ ' _ TOWN OF NORTH ANDOVER
computer,use f L� '!� HEALTH DEPARTMENT
only the tab key Address
to move your North Andover MA 01845
cursor-do not ------.....-----.__._._.._.- ___—._........---_W........_..--...
use the return City/Town State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
City/Town State n Zip,
Pyode �
Telephone Number
B. Pumping Record
1. Date of Pumping -DI ate ---- 2. Quantity Pumped: Gallons
�
D
3. Type of system: ❑ Cesspool(s) ,, eSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present?.0 Yes ❑ No If yes; was it cleaned? 2"Yes ❑ No
5. Condition of System:
0k
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.govldep/water/approvalslt5forms.htm#inspect
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