HomeMy WebLinkAboutGrease Tank - Septic Pumping Slip - 3/23/2020 Commonwealth of Massachusetts
W 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 Mitt
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(When filling out 1. System Location: IDw �NDE pR�MEN�
forms on the `(yam ` H
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 � Zi Code
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Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped. Gallons� d
3. Type ystem: [ICesspool(s) El Septic Tank ❑ Tight Tank
Other(describe): r' SGRT
4. Effluent Tee Filter present? ❑ Yes � If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped B
�I
Na—me"ram Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
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Signature of Mauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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