HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 TUCKER FARM ROAD 3/23/2020 Commonwealth of Massachusetts
City/Town of NORTH AN®OVER, fIIIASSACHUSETTS
-- System Pumping Record
M 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
Important:
When tilling out 1. System Location: Ned.
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:
Name
Address('rf different from location)
—.......-- .........
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes [9'No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number -
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of HaulerV Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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