HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 729 BOXFORD STREET 12/4/2019 Commonwealth of Massachusetts
-`b City/Town of NORTH ANDOVER, MASSACHUSETTS
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System Pumping Record Y p g
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.
REC��-z:1_V icD
A. Facility Information DEC O 4 2019
Important: 19
When filling out 1. System Location: TOWN OF NORTH ANDOVER
forms the •'�C HEALTH DEPARTMENT
computer.use
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:
Name
Address(if different from location)
City/Town State Zip Code
R7S &4 1'7-qj
Telephone Number
B. Pumping Record
G � 1
1. Date of Pumping Date • d r 2. Quantity Pumped: Gallons' �
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [/No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: a
6. System Pumped By:
Name Vehicle Ticense Number
Wind River Environmental
Company
7. Location where contents were disposed: ITP
1
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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