HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 18 MARGATE 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 Pura ust
be submitted to the local Board of Health or other approving authority. EE
A. Facility Information DEC
Important: TOWN OF NORTH ANDOVER
When filling out 1. System Location: HEALTH DEPARTMENT
forms on the
computer,use - ---..__�/=_1.A ......�-�_...._....._...._._..................._..- - ..........—_.
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 Zp Code
f
L� 11 t
Telephone Number
B. Pumping Record / 1
1. Date of Pumping pate G 2. antity Pumped: Gallons
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 System: o
6. System Pumped By: G,L.S.D.
North Andover- MA�
-- - --...............
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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