HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 MARIAN DRIVE 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: TOWN OF NORTH ANDOVER
when filling out 1. System Location: HEALTH DEPARTMENT
forms on the ��-
computer,use _—.. >)'C®V� - .—....—.__.—..__ —.�—_..._�....�...—..._..
MA
only the tab key Address
to move your North Andover 01845
cursor-do not
use the return
City/Town State Zip Code
key. 2. System Owner:
�Y b f<i
Name
Address(if different from location)
State Zip Code
CitylTown �01
Telephone Number
B. Pumping Record
Ii. LA. p W
Dat e e
1. Date of Pumping ! �— 2. Quantity Pumped. Gallons
D
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 -- g.Wtg TR
7. Location where contents were disposed: Ipswich, MA.
Signat re of Hauler Date
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
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