HomeMy WebLinkAboutSeptic Pumping Slip - 500 GREAT POND ROAD 5/15/2017 kECEIVED
�L\ Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSEX F.NORT14 ANDOVER
, l 4 MUXI I
System Pumping Record IJL,, MULMAK
Form 4
DEP has provided this form for use by local Boards of Health.' The System Pu ping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out I System Location-,
forms on the �6� y,Pu
computer,use Soo
only the tab My Address
to move your North Andover MA 01845
cursor-do not City/Town Ttite_ Zip Code
use the return
key. 2. Syste Owner:
4�� b
Name
Address(if different from location)
Cityrrown Stale
4!ppe
'relephoneNumber
B. Pumping Record
1, Dote of Pumping 6 2. Quantity Pumped: CO
Date Gallons
3. Type of system: [] Cesspool(s) ❑ Septic Tank Tight Tank
F1 Other(describe):
4. Pffluent Tee Filter present? M Yes No If yes,was it cleaned? [I': Yes El No
5. Condition of System:
C) 6
6. System Pumped By: qf- ?
Mame'so
Vehicle License Number
Wind River Environmental
Company
7. 'Location where contents were disposed: STEWARTS SEPTICi SERVICE
58 801 IT
BRADFORD, MA 6.1 WS
Signature of Hauler
http://www,mass,gov/dep/water/approvels/t5forms.htm#inspect
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