HomeMy WebLinkAboutSeptic Pumping Slip - 835 CHESTNUT STREET 12/19/2017 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHU
SETT.
stern P alt,
!� umping Record � .41
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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.
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A. Facility Information
Important:
When filling out 1. System Location:
forms on the 7 /
computer,use Jil�'�' s y
only the tab key Address
to move your North Andover
cursor-do not __ MA 01845
use the returnCity/Tawn —� State
key. Zip Code
2. System Owner:
raa b RG(
Address(if different from location) -
Citylrown ^' State p ] Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date/—/ �-� 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ((Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
r I
6. System Pumped By:
Wind River Environmental Vehicle License Number
_
Company --------._-------
7. Location where contents were disposed: t y
.�t �� t �" `4� �� ttt y
p: g
Si nature of Hauler Date r --
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t5form4.doc•06/03
System Pumping Record•Page 1 of 1