HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1072 JOHNSON STREET 12/4/2019 Commonwealth of Massachusetts
a Cit /Town of NORTH ANDOVER, MASSACHUSETTS
City
[Town
Pumping Record
Form 4
Mom.
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. System Location: TOWN OF NORTH ANDOVER
forms on the HEALTH DEPARTMENT
computer,use _`Y
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:
r b
Name
ttrn Address(if different from location)
City/Town State` Zip Code —
7b�1��
Telephone Prumber
B. Pumping Record
1. Date of Pumping ----- - 2. Quantity Pumped: -- --
Date Gallons
3. Type of system: ❑ Cesspool(s) II Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2/No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
--_ _. -.....--—...-- _............— _...-
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
.._........... _......__.....
Company
'AN1WT R
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
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