HomeMy WebLinkAboutSeptic Pumping Slip - 1980 TURNPIKE STREET 2/20/2018 Commonwealth Of MSI ssachu(S)etts RECEIVED
1 � City/Town of NORTH ANDO MASSACHUSETTS-EB 2 0 2018
System Pumping Record �
THAN
Form 4 I OF
F.ALTB°i DEPARTMENT
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 titling Out 1. System Logation:
forms on the
computer,use _�. (�t/ l (/yl (/ /✓ /t t
only the tab key Address
to move your North Andover _MA g1g45
cursor-do not -- -- �_ �..__ . _ _
use the return City/Town State —
Zip Code
key. '
2. System O net,:
VQ b__ �ej
71
rrrm Address(if different from location)
City/Town,......,.. -
State
Telephone Number
B. Pumping Record
1. Date of Pumping
2• Quantity Pumped: Gallons -
3. Type of systems: ❑ Cesspool(s) .Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Na If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System u ed By'
VohicVe License Number
Wind River Environmental
p Y r �j
7. Location where co nts were disposed:
,U
Sig r of Hauler Date
http://www,mass.govldep/water/approvals/t5forms.htm#inspect
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