HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1468 SALEM STREET 12/4/2019 Commonwealth of Massachusetts
p City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
^� Form 4
DEP has provided this form for use by local Boards of Health. The Syste tgp�ijtg_Eccord must
be submitted to the local Board of Health or other approving authority. ep9
A. Facility Information DEC 0 4 2019
Important: TOWN OF NORTH ANDOVER
When filling out 1. System Location: HEALTH DEPARTMENT
forms on the `��� n
computer,use y _ _T� fi.
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:
b i9 n c1 (�( f Gtn
Nanfe J
eQe r 4 Address(if different from location)
City/Town State Zip Code
et -7 -7 S N -1 31 Li
Telephone Number
B. Pumping Record
1. Date of Pumping tL`- -�- - 2. Quantity Pumped: S —
Date 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 f.W. T.P
7. Location where contents were disposed: Ipswicli, MA.
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