HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1469 SALEM STREET 3/23/2020 Commonwealth of Massachusetts
MASSACHUSETTS
W City/Town of NORTH AND
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumpiog Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility information
OwN of N E�MEND
Important: •( � ��H
When filling out 1. System Location:
forms on the ( L- G 9 ,1—'1 C
computer,use
only the tab key Address MA 01845
to move your North Andover Zip Code
cursor-do not State
City/Town
use the return
key. 2. System Owner:
bVQ DC�
Name
Address(if different from location)
State Zip Cod
Cityrfown ch 2 � _'
Telephone Number
B. Pumping Record 1000
1. Date of Pumping `LC5
Date
2. Quantity Pumped: Gallons
Cesspool(s) '�Setic Tank ❑ Tight Tank
3. Type of system: ❑ p
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes,�No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: 3-3`U
l�AzQe C UJ Vehicle License Number
Name
Wind River Environmental
Company _
7. Location where contents were disposed:
6 1b t$u9i V e 4
4,; S P rtn—
Date '€�
Signature of Hauler
http:l/www.mass.gov/dep/water/approvalslt5forms.htm#inspect
System Pumping Record•Page 1 of 1
t5form4.doc•06/03