HomeMy WebLinkAboutSeptic Pumping Slip - 740 FOREST STREET 6/15/2017 PECEIVED
4
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTSJ�J2()
System Pumping Record TOWN OF NORTH ANDOVER
orm 4 HE LTH DEPARTMENT
F
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
Impodant:
VVhgn filling out 1 8ysqtem Location,
forms on the
Computer,Use �(o
only the tab key Address
to move your North Andover MA 0.1845
cursor-do not Qityrr;wn �te 4p Code
use the return
key.
2. System Owner:
b n
Name
rd�dress(ifdifferent fromtowlon) ���
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping2. OnfiSC)
Quantity Pumped: _-6
O4D � uaGallons
3. Type of system; El Cesspool($) Septic Tank EJ Tight Tank
El Other(describe);
4. Effluent Tee Filter present? E] Yes No If yes,was it cleaned? Fj Yes E] No
5, Condition of System:
r.bc-J
6. System Pumped By,
1
r— -
--
Name vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Haverhill WWTP
40 fter St
rA-M"-*tM I
Signature of Hauler 10r4Adb
http://www,mass.gov/dep/waterlapprovals/t5forms,htm#inspect (978) 374-2382
t5form4,doo, System PurqpIng Record-Page 1 Of 1