HomeMy WebLinkAboutSeptic Pumping Slip - 101 GRANVILLE LANE 11/27/2017 Commonwealth of Massachusetts
City/Town of NORTH AND MASSACHUSETTS
System Pumping Record
s` Form 4
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
Important:
When filing out1. 5 stem Locati0 ;
forms on the
computer,use
only the tab key Ad ress
to move your North Andover MA
cursor-do not 01845
use the return CityfFown SEate
Zip Code
key.
2. Systemweer:
b to"0\IC,h
Name
Address(if different from location
CityFfown Slate � fZip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Zo� 2. Quantity Pumped: U ...,
Gallons
3. Type of system: ❑ Cesspool(s) r, Septic Tank
El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes V-No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: 9C
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Haverhill 'WWTP
Signature of Hauler
http://www,mass.gov/dep/water/approvals/t5forms.htm#inspect (978) 3742382
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