HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 JERAD PLACE 12/4/2019 Commonwealth of Massachusetts
_ = -(P City/Town of NORTH ANDOVER, MASSACH_USETTS
-_ System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System must
be submitted to the local Board of Health or other approving authority.
Ke
A. Facility Information
TOWN OF NORTH ANOOVER
Important: HE �'�PkRTMENT
When filling out 1. System Location:
forms on the
computer,use � ..—�F�_t� .. 0 _ ---......—..._—..... —.^... ---
only the tab key Address —
to move your North Andover MA 01845
cursor-do not --- _—._. .....—_...._ —__ ---.-
use the return City/T°wn State Zip—Code
key. 2. System Owner: f
b AL�
Name
Address(if different from location)
------.....-
State Zi Code
Ci ty ITown s (-"\ �r
Telephone Number
B. Pumping Record
1. Date of Pumping - 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ,Ff 'Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes0-INo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
0.P-cLA S .. Z 3
Name Vehicle License Number
Wind River Environmental
C-Ompany --- _.. ...
G.L.S.D.
7. Location where contents were disposed: North Andover, MA.
Signature of Hauler Date
http://Www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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