HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 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 System Pumping Record must
be submitted to the local Board of Health or other approving authority.' ECEIVED
A. Facility Information DEC 0 4 2019
Important:
When filling out 1. System Location: jf TOWN OF NORTH
ANDOVER
forms an the ` -� rO// HEALTH DEPARTMENT
computer,use ---..._........._...
only the tab key Address
to move your North Andover MA 01845
cursor-do not City —............_....._..�----.--.__^____.._. --....� p
use the return Ci !Town State Zi Code
key. 2. System Owner:
VP b
Name
Address(if different from location)
City/Town State ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping .� 2. Quantity Pumped: `
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
Other(describe):
(.K'�s e-
4. Effluent Tee Filter present? ❑ Yes [Sr No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-,
---_.....__.___.........._ _-------
6. System Pumped By:
Name Vehicle Licen a 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
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