HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 980 FOREST STREET 12/4/2019 Commonwealth of Massachusetts
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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- rd must
be submitted to the local Board of Health or other approving authority.
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A. Facility Information BEG n T
TOWN OF NORTH ANDOVER
Important: HEALTH DEPARTMENT
When filling out 1. System Location:
forms on the
computer,use —_......... dr -'--........
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 Zip Code
q-7 cS z1y t' j C)L-1
Telephone Number
B. Pumping Record
1. Date of Pumping Date - 2. Quantity Pumped: -Gallons
1 Type of system: ❑ Cesspool(s) [2"Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present?16Yes ❑ No if yes, was it cleaned? ❑ es ❑ No
5. Condition of System:
6. System Pumped By:
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 e ,' Pumping Record-Page 1 of 1