HomeMy WebLinkAboutSeptic Pumping Slip - 78 LACY STREET 1/2/2018 `` Commonwealth of Massachusetts
(w City/Town of NH A DOVER, MASSACHUSETTS
x System Pum in Regard .--
/�i Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must t
be submitted to the local Board of Health or other approving authority.
f
A. Facility Information 8l " L'-�"
Important:
When filling out 1. System Loc tion:
forms on the
computer,use j YG C 4SV
only the tab keys
to move your North Andover
cursor-do not _.__._,_ MA
use the return City/Town ____._ _ _ _ State -- Zip Code
key. _ 2. System O er:
�4 b
ame
Address(i(different from location)
Cit !Town
l
y State
J," p301�
Telephone Number
B. pumping Record
-
1. Date of Pumping Dat 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank F1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
-!-�-A__ I SCS
Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
%�"���i�ll W"fi
--�
Signature °f
of Hauler — � ��
http://www.mass.gov/dep/water/approvals/t5fortns.htm#inspect f978) 374-2,382
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