HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 CROSSBOW LANE 12/4/2019 Commonwealth of Massachusetts
City/Town of NORTH AN®OVER, MASSACHUSETTS
System Pumping Record
k\ �� Form 4
DEP has provided this farm for use by local Boards of Health. The System f3gWop ecqVd must
be submitted to the local Board of Health or other approving authority.
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A. Facility Information `� � `v
TOWN OF NORTH ANDOVER
Important: HEALTH DEPARTMENT
When filling out 1. System Location:
forms on the L �� CA
computer,use _ V _ =._ ' "ti.•_.... _._.._._ ......
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:
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Name
Address(if different from location)
City/Town State Zip Code
_ i�- 2
Telephone Number
B. Pumping Record i
1. Date of Pumping —Ai i� -- 2. Quantity Pumped: wo
Gallons
Date
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes. I'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.L,,.S.LTT11
.
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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