HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 TUCKER FARM ROAD 12/4/2019 -. Commonwealth of Massachusetts
R_ — - (p City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
'M 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 ANDOVER
forms on the `•_ �V��`� HEALTH DEPARTMENT
computer,use r —_—___.._._ __..__......
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:
brY-\ ;V_(! :AP
Name
Address(if different from location)
City/Town State Zip Code
�
7 2 '� 7 �
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes,.a o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
_-.._...._..........--
6. System Pumped By:
r"""Or a CV'
Name Vehicle License Number
Wind River Environmental
Company
G.L.S.D.
7. Location where contents were disposed: North Andover, MA-
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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