HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 325 BERRY 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.
A. Facility information
Important: �N P`yVE•`
fo hms onen lltheout 1. System Locatioon: �D N ��NO�✓�PQ�t��N1
computer, use z S
only the tab key Address
to move your North-Andover
cursor-do not MA 01845
use the return City/Town State
key. Zip Code
2. System Owner:
b 0�1 PA
Name
Address(if different from location
City/Town State
Zip C
qg ode
7 S-
Telephone Number
B. Pumping Record
1. Date of Pumping z
Date 2. Quantity Pumped:
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:
zD
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06/03
System Pumping Record•Page 1 of 1