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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 3/23/2020 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 ©EP 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 NOFNOR`HR�M��� Important: �Ow�L�NDD4P When filling out 1. System Location: H forms on the computer,use _...._..__... ._._....._._...__-- only the tab key Address — to move your North Andover _ MA 01845 cursor-do not City/Town _ State Zip Code use the return P key. 2 System Owner: b gC-1r) Lny Name xern Address(if different from location) City/Town State Zip Code q '7 Telephone Number B. Pumping Record 1. Date of Pumping -- 2. Quantity Pumped: — Date Gallons 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: 6. System Pumped By: Name Vehicle License Number Wind River Environmental Company 7. Location where contents were disposed: Signature of Hauler Date ;., tom: ti http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect BIN 'P �� IS J9,U0d S .. t5form4.doc•06103 a wr. ;� n Record-Page 1 of 1