HomeMy WebLinkAboutSeptic Pumping Slip - 1499 SALEM STREET 10/13/2012 Commonwealth of Massachusetts Corm 4--System Pumping Record
Massachusetts >a .
System Pumping Record RECEIVED�
System Owner System Location
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Type: Emergenc Routine
Cesspool: No — Yes Septic Tank: No Yes
Date of Pumping: D Quantity Pumped: f/ Gallons
System Pumped 6y: Wind River Environmental,LLC Permit#:
Contents Transferred to:
I
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Contents Disposed at:
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Date: 0 f _ Pum er Si nature:
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Condition of System/Other Comments
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I'rincedonree),I dpaper Dep Approved Form-12/07/95
a x Commonwealth of Massachusetts
City/Town of
ANDOVER
System Pumping ®r a
Form 4
N
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
When filling out 1. System Location:
forms on the 9-- . C —
L l _L kAy
computer,use '
" " --
only the tab key Address p�� ,f r'
to move your
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from to-
o-cation)
--- ---------_- ------ State Zip Code
City/Town ,
Telephone Number
B. Pumping Record
2. Quantit y Pum p ed:
1. Date of Pumping Date -------- Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- — ---- ---_._
4. Effluent Tee Filter present? [/Yes ❑ No If yes, was it cleaned? L Yes ❑ No
5. —Condition of System:
& System Pumped By: ry
---- 1 " j 1�uY1 ...— - --- Vehicle ( ----- ----
N�me t.,,, — — � se Number
Company
7. Location where contents were disposed:
— ----- – —
L w�
Signature of Hauler to
Signature of Receiving Facility Date
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