HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 143 PHEASANT BROOK ROAD 12/4/2019 � , Commonwealth of Massachusetts
_- ;p City/Town of NORTH ANDOVER, MASSACHUSETTS
'IIVV'' System Pumping Record
i 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: 7 HEALTH DEPARTMENT
forms on the p �f + -� C +(�- i- 9, �,.:`t t
computer,use t 43 ` ��
only the tab key Address
to move your North Andover MA 01845
cursor-do not _......... ..... _.._— _... — -- _..
use the return City/Town S#ate Zip Code
key. 2. System Owner:
b <e j?�N (l t e �121?v,\A C-(Jq
Name
Address(if different from location)
City/Town State --7Zip Code
Telephone Number
B. Pumping Record
f_.
1. Date of Pumping t / — 2. Quantity Pumped: Ga
Date l►ons �
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [_1 Yes Z] No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
C)v----- _._.. .._. _..—_............_.........--------- -........—......
---..- -
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company- L W.W.T.P
7. Location where contents were disposed: IP9vich, MA
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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