HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 650 FOREST 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.
RECEIVE
A. Facility Information
Important DEC O � 2011an
When filling out 1. System Location:
forms onthe / (o(-C �/_ (��Ce re TOWN NORTH ANDOVER
computer,
r.0 r,use � J HEALTH DEPARTMENT
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 F->09 GC)k fld
Name
Address(if different from location)
City/Town State q�n 9� � Zi :ode�
Telephone Number
B. Pumping Record C
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Q�Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes, 'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
t^\A zcc)j
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date S. .
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspects}` ar MA
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