HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 78 LACY STREET 12/4/2019 Commonwealth of Massachusetts
,4 City/Town of NORTH ANDOVER, MASSACHUSETTS
i System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System EiVEDd must
be submitted to the local Board of Health or other approving authority.
BEG-0 � 2019
A. Facility Information
Important: TOWN OF NORTH ANDOVER
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P HEALTH DEPARTMENT
When filling out 1. System Location:
forms on the -7 Q /' !1 C y( S L�� �
computer,use J (�t—� l L __._............_.._.___
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'�Ow,ner: /
bpi—try
Name
Address(if different from location)
City/Town State /I 1 -- ��� God
Telephone Number
B. Pumping Record
ff /
1. Date of Pumping l t0 2 Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes O No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
0_1 _. — —_...._._...- _......__ ............
6- System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Da
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect OP GL
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