HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 176 VEST WAY 12/4/2019 .............. . .
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
' .. System Pumping Record
% I Form 4
DEP has provided this form for use by local Boards of Health. The System PtrC1Y G�must
a
be submitted to the local Board of Health or other approving authority. �V b
A. Facility Information DEC
Important: TOWN OF NORTH ANDOVER
V/Vhen filling out 1. System Location: HEALTH DEPARTMENT
forms the 1 (p V'oIsm
computer,
r,use
only the tab key Address a^
to move your North Andover MA 01845
cursor-do not — --use the return City/Town State Zip Code
key. 2. System Owner-,
mz b 6a J IL �
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date g^� 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) fi Septic Tank ❑ Tight Tank
❑ Other(describe): �+
4. Effluent Tee Filter present? ❑ Yes [?J No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: a
— -._...........-- --.._.....-tom ...-------_ _....
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.gov/dep/Water/approvals/t5forms.htm#inspect
I.WWT.P
t5form4.doc-06t03 IpsWif #ig Record•Page 1 of 1