HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 34 BOXFORD STREET 3/23/2020 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.
A. Facility Information
Important:
When filling out 1. System Location:
forms the 3 9
computer,
r,use "'f ((��
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
rab b
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Gallons
�O 2. Quantity Pumped: Gali /
3. Type of system: ❑ Cesspool(s) [A Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: /
W r `_ �(?
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
40 a f_
¢,real ra
�3p..
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