HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 140 MILL ROAD 12/4/2019 Commonwealth of Massachusetts
City/Town of NORTH AN®OVER, MASSACHUSETTS
- System Pumping Record
-�
F� 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 4 201.9
Important:
When filling out 1. System Location: TOWN OF NORTH ANDOVER
forms on the -f/ HEALTH D-PARTMENT
computer,use
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 r�t� l
Name
Address(if different from location)
City/Town State
., Zip Code
// 7 i Cif •
Telephone u`I1 m—
B. Pumping Record
1. Date of Pumping — - -t --- 2. Quantity Pumped: -- -
Date Gallons
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [KNo 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:
Signature of Hauler Date S
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect Qr• •�
Oyer.
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