HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 HAY MEADOW ROAD 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 REetIVED must
be submitted to the local Board of Health or other approving authority.
A. Facility Information DEC 0 4 201Q
Important: TOWN OF NORTH A.NUOVER
When filling out 1. System Location,-
forms on the i / ` rk
computer,use C {�
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
b ..�o /-14 Q
Name
' Address(if different from location)
City/Town State � ^--�� �Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yesf�'No 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:
LSD.
dover,
,forth An
Signature of Hauler Date
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
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