HomeMy WebLinkAboutSeptic Pumping Slip - 30 MILL ROAD 5/21/2018 Commonwealth of Massachusetts
City/Town of NORTH NDQ�LE MASSACHUSETTS
} Pumping Record
Systemp g
Farm 4
DEP has provided this form for use by local Boards of Health, The System Pu pin Re
be submitted to the local Board of Health or Other approving authority, CCFC PAE
A. Facility Information
Important:
When filling out 1. Sy Location: �/ {
forms the 4 I 1 I t
computer,use
only the tab key Addressto move your North Andover
cursor-do not -------a_._.._ _......_.— __� _�. MA 01845
use the return
City/Town State _ Zip code —
key,
2. System O er:
b C+C
C.w
Name
Address(if different from
ylTownSkate ___ .____..
Zip Code J ,
Telephone Number
B. Pumping Record
(� '� a(5> 201 I
1. Date of Pumping a - - - - 2, Quantity Pumped: r �
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 ❑ Na
5. Condition of System:
6. System PuTKd By:
Name Vehicle License Number
Wind River Environmental
7. Location where contents were disposed:
Signature of Hauler �— Date- —
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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