HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 RALEIGH TAVERN LANE 3/23/2020 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
= r 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 �� PNouv
Important: NpVAO\
When filling out 1. System Location:
forms on the
computer,use _"�c_�r�_ _j�� p,
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 OO�w�ner:
� �f e-
b O A
Name
Address(if different from location)
City/Town State Zip Code
617 Lk
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Q. antity Pumped: Gallo`ns
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes,was it cleaned? Yes ❑ No
5. Condition of System:
0pp�� A
6. System Pumped 40 S Porter St
�.- Bradford, Ma 01835
Name Vehicle Li bey .�- —__73.. 2
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://Www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
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