HomeMy WebLinkAboutGrease Tank - Septic Pumping Slip - 757 TURNPIKE STREET 3/23/2020 Commonwealth of Massachusetts
- =-- City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
%1 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 NWN
Important:
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When filling out 1. System Location:
forms on the
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:
b �7 ; Vl
Name
" Address(if different from location)
City/Town State 78 (b j Zip 6
Telephone Number
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B. Pumping Record
1. Date of Pumping Date
' 2. Quantity Pumped: Gallons
Ca
1 TrOther
stem: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Alt�----
6. System Pumped Bye
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: A•
Signature of H uler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect ,
t5form4.doc-06/03 System Pumping Record•Page 1 of 1