HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 29 WILDWOOD CIRCLE 12/4/2019 141,
Commonwealth of Massachusetts
---�6 City/Town of NORTH ANDOVER, MASSACHUSETTS
r y System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System FhPWq.Rec;v must
be submitted to the local Board of Health or other approving authority.
nrn n A �n,n
A. Facility Information DE6 u 4 cu l7
TOWN OF NORTH ANDOVER
Important: HEALTH DEPARTMENT
When filling out 1. System Location:
forms on the
computer,use _ _..._.. - - -..........
only the tab key Address
to move your North And MA 01845
cursor-do not _..... _ .._.._ --__
Andover -- —
use the return City/Town State Zip Code
key. 2. System Owner-
V1 Q
b EL
IL JW Name
+ Address(if different from location)
Citytfown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - �Septic
tity Pumped:
Gallons
ons
3. Type of system: ❑ Cesspool(s) ank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi n of Sys em:
6. System Punjr
Name Vehicle License Number
Wind River Environmental _ �r±± Q
Company 7£8 to evy `paolpe,13
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1