HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 216 FOSTER STREET 12/4/2019 1 \ Commonwealth of Massachusetts
c1 =--,p City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
5 `
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. S stem Location: TOWN OF NORTH ANpOV
forms on the HEALTH DEPARTAiIW
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 Owner:
b l Ago A SO e o(-,,j -
Name
' Address(if different from location)
City/Town State � � � Q ip Code r,
Telephone Number
B. Pumping Record
1. Date of Pumping ( " Z# - - 2. Quantity Pumped:
_....
Date Gallons
3. Type of system: ❑ Cesspool(s) eSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ZNo If yes; was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
�r
Signature of Hauler Date �y
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
System Pumping Record�- age 1 of 1
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