HomeMy WebLinkAboutSeptic Pumping Slip - 24 GILMAN LANE 10/16/2017 Commonwealth of MassachusettsRECEIVED
mm: City/Town of 0o, ) T 16 2017
System bumping Record
-A Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health, Other forms n•iay 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 75.351,
A. Facility Information
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Zip Code
2, System Owner:
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Name . . _...._ _
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Address iif different from
State
Zip Code
Telephone Number
B. Pumping Record _
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1 Dake of Pumping are -- __..___. 2 Quantity Pumped;
Gallons
3 Component: ❑ Cesspool(s) Septic Tank ❑ flight Tank ❑ Grease Trap
❑ Other(describe):
4 Effluent Tee Filter present? ❑ YesNo If yes, was it cleaned? ❑ Yes ❑ No
5 Observed condition of component purnp\ed:
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Nam
beh�cte Ucense Number
Wind River Environmental
Company
Location where contents were disposed, Ipswich, MA.
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t _.....__.�...__...,_,._._......,,..., _—
S�gnatu—ure—or".Hauler Date _...�.___..._
Signature of Facor attach facility
4 f R- Facility Receiving-- � Y t y rererpt} Dare _._._..__..._ ....
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System Pumping Record•Pau, i 1r6 t