HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 TUCKER FARM ROAD 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. RECEIVED
A. Facility Information DEC 0 4 2019
Important:
When filling out 1. System Location: TOWN OF NORTH AND(�VE
forms on the i DE?/�RTVI�NT
computer,use
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:
Name
Address(if different from location)
City/Town State Zi Code
4t78 `�Li �I0
Telephone Number
B. Pumping Record
1. Date of Pumping I -�.-� 2. Quantity Pumped: ....... --
Date Gallons
3. Type of system: ❑ Cesspool(s) 2f 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:
_._....._._._......._..---- LLJ ILI
6. System Pumped By:
w 2 7 3S0
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
G.L.S.D.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06103 System Pumping Record•Page 1 of 1