HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 111 CROSSBOW LANE 12/4/2019 =� Commonwealth of Massachusetts
-- -ib City/Town of NORTH ANDOVER, MASSACHUSETTS
-,� System Pumping Record
Form 4
DER 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
Important:
When filling out 1. System Location: TOWN OF NORTH ANDOVE
forms on the HEALTH DEPARTMENT
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. System Owner:
b serf#�+`A t
Name
Address(if different from location)
City/Town Stater Zip Code
CI 7.8
Telephone Number
B. Pumping Record
1. Date of Pumping oatI.eV -6` 2. Quantity Pumped: gallons ..._............
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [ Yes ❑ No If yes, was it cleaned? [/Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number—
Wind River Environmental Company I.WW E
7. Location where contents were disposed: Ipswich, MA
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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