HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 743 WINTER 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:
When filling out 1. System Location: TOWN OF NORTH AWOVER
forms on the ( , S HEALTH DEPARTMENT
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 Owne
o
b •.
Name
Address(if different from location)
City/Town State Zip Code
Telephone umber T79 J�'79 t-L S
B. Pumping Record q
1. Date of Pumping Date 2. Quantity 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 SSlyst m
b 4
6. System Pumped
Name Vehicle License Number
Wind River Environmental G.L.S.D.
Company North Andover, MA.
7. Location where contents were disposed:
Signature of Hauler Date
hftp://www,mass.gov/dep/water/approvals/t5forms,htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1