HomeMy WebLinkAboutSeptic Pumping Slip - 946 OSGOOD STREET 12/19/2017 Commonwealth of Massachusetts
(� City/Town of NORTH ANDOVER MASSADHUSETT
System Pumping Record `�
Form
q,ry p y r
1 R/rI1�1 4 "Alk
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 filling out 1. System Location:
forms the /
computer,use
only the tab key
to move your North Andover _ —
cursor-do not MA 01845
use the return cit own __ ---
key. Zip Code
2. System
y /Owner:
Name
" Address(if different from location -
City/Town �— � Stake ----�
Zip Code
- '�'_
Telephone Number
B. Pumping Record
1. Date of Pumping �"/� �� .�
Datt e �. Quantity Pumped: _
Gallons
3. Type of system; ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
a Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2 No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
-�
6. System Pumped By;
Name �-
Vehicle License Number
_Wind River Environmental
Company --- _
7. Location where contents were disposed;
�s SEPTIC SERVICE
�:i�T��NAP,y
58 SOUTH
Signatureof Hauler y'"'--"3RAD•�FORD,,MA 01835 — -
Date
http,//www.mass,gov/dep/water/approvals/t5forms.R§r p c7471
t5form4.doc•06/03
System Pumping Record•Page 1 of 1