HomeMy WebLinkAboutSeptic Pumping Slip - 1801 TURNPIKE STREET 4/11/2017 CommonweaWng
c ausetts
City/Town of
R - - System Pumuord
yForm 4
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 informations
Important:When
filling out forms 1. System Location:
on the computer, r
use only the tab yrr r —w ---
key to move your Address
cursor-do not _,41,e 4., MA
key.
use the return Cityf Town , —:A State Zip Code
2. System Owner:
f�yy �T
Name
Address(if different from location)
City(Town State zip Code --
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: Galla --
Date
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee f=ilter present? ❑ Yes O"No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
ale
-
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental Wind River Envirannentaf
Company 163 Western Ave.
7. Location where contents were disposed: GIOUCCSter, MA 01930
Stewarts Septic _......
_ 58 !MbaLStrr,n# --_
Signature of Haul&W ford, MA 01835 Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4,doo• 11112 System Pumping Rerord•Page 1 of 1
Z\ Commonwealth of Massachusetts
uv� "
ity/Town of
SystemPumping Record NORTH ANDOVER
Form 4
01=P has provided this form for use by local Boards of Health, Other forms may ba used, but the
information must be substantially the same as that provided here- Before using this form, check with your
local aoard of Health to dete"ine 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 95.351.
A. Facility Information
Important;
vvben filling but 1. System Location:
forms on the
m.� .. _.. c► .._ - --- ...- .._ .._ _.
computer,use ,.,.. .-.........�._.,,.,._
only the tab key
to move your �-`- -
cursor-do not —........ _...
use the return cityrrown State zip Code
key. 2. Syste wne�rF
Name
Address(If different from location)
Cit £rbwn Stale
Telephone Nurnber
B, Pumping Record
1. date of Pumping �{ 2. Quantic Pumped:
Date
Gallons
3. Type of system: ❑ Cesspool(O Ck Septic Tank ❑ Tight Tank [] Grease Trap
❑ Other(describe): . ._. _.._._ _.. . -- .._. _... . .._. ........ - - - - -
4. Effluent Tee f=ilter present? Q "YesA No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pu=d Sy:
Name Vehicle License Number
Company
7. Location where cop#ents were disposed'
Signature of hauler pate ,W. T.PMA.
�.._..... ..
$igrtatur�of Receiving Facifty fate
15form4.doc,03106 System Pumping Record P99e 7 of 9