HomeMy WebLinkAboutSeptic Pumping Slip - 37 STONECLEAVE ROAD 4/3/2018 ., Commonwealth of Massachusetts
ECEIVED
City/Town of NORTH ANDO10ER MAa�AD
s HUSET a
System Pumping Record n� lt(116
T �
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must 1
be submitted to the local Board of Health or other approving authority. 1
A. Facility Information
Important:
When filling out 1, stem Location:
forms on the �((
computer,use �Jv _ ` ? ti Jy)<�-
only the tab key Address
to move your North Andover
cursor-do not — --- _. MA 01845
use the return City/Town _______..._.__._ State _ --"
Zip Code
key. 2. System ner:
VQ
flame
Address(if different from location) —_._.—~ _- -- — --- ---
City/Town
State Zip Code —
Telephone Number
B. Pumping Record
1. Date of Pumping �` a _--61;' Q� 2. Quantity Pumped: -_-t-�
Gallons
3. Type of system: ❑ Cesspool(s) V�Septic Tank ❑ Tight Tank
❑ Other(describe):4. Effluent Effluent Tee Filter present? ❑ Yes d'No If yes, was it cleaned? ❑ Yes ❑ IVa
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
—Zor .
Company ---
7. Location where contents were disposed:
Signature of Hautes — Date
http://www.mass.gov/dep/water/approvals/t5forms,htni inspect W.
'Pswich, A4A.
t5formI 06/03 System Pumping Record•Page 1 of 1