HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 138 LACY 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. o' ?
A. Facility Information oFNOR ��ME
Important: N \� \Ap�pF
When filling out 1. System Location:
forms the
computer,
r,use
only the tab key Address to move your North Andover MA 01845
cursor-do not --. -._
—._.—..—_._
use the return C' /Town State Zip Code _ --
key.
2. System Owner:
br bcs('ilc
Name
` Address(if different from location)
City/Town State Zip Code
5-7�f ';-C'9 56-76Y
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped.-
Gallons
3. Type of system: ❑ Cesspool(s) 2rSeptic 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:
3 cj
Name Vehicle License Number
Wind River Environmental
Company —
7. Location where contents were disposed:
e7
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
c46 A
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