HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 107 GRAY STREET 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 Systerriltepi ff d must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important: TOWN OF NORTH ANDOVER
When filling out 1. System Location: HEALTH DEPARTMENT
forms on the .t G-7 ! � y
computer,use ._._...._. l _...... ._
only the tab key Address
to move your North Andover MA 01845
cursor-do not -- — _ ......._ _.
use the return City/Town State ZipCode
key. 2 System Owner:
Name
Address(if different from location)
City/Town State Zip Code
657
Telephone Number
B. Pumping Record
1. Date of Pumping —�-�-L -,- 2. Quantity Pumped: f S�
Date Gallons
3. Type of system: ❑ Cesspool(s) ]Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 1;4�es ❑ No If yes, was it cleaned? dyes ❑ 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 Haul r Date
http://www,mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1