HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 44 BRUIN HILL ROAD 12/4/2019 Commonwealth of Massachusetts
-- -- ; City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
5�.
€}EP 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.
REC.—CIVICD
A. Facility Information q
Important: DEC O � 2�
When filling out 1. System Location:
\ p ' TOWN OF NORTH ANDUVER
forms on the
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computer,use _ _.. �..._ ._.__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 Owner:
rz5 b
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
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1. Date of Pumping Date /" LSeptic
ntity Pumped: Canonsf s stem: Cess ool s Tank ❑ Tight Tank
3. Type o y ❑ P ( )
❑ Other(describe):
4. Effluent Tee Filter present? ET Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
b
6. System Pum ed B : .L.S.D.
North Andover, MA.
Name— - ...__........ --.._ _
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www,mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record-Page 1 of 1