HomeMy WebLinkAboutSeptic Pumping Slip - 7 DUNCAN DRIVE 5/21/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
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DEP has provided this form for use by local Boards of Health. The Syste pir1 ust
be submitted to the local Board of Health or other approving authority. gf ��n
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A. Facility Information
Important:
When filling out 1. System Location.
forms on the
computer,use
only the tab key Address --to move your North Andover
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cursor-do not -- - —
use the return City/Town � �---�� State _ Zip Code _-
key.
2. Syste
b m Qgwner:
`+
Name
(if Address different from location)
Clt ITawn
y Slate Zip Cod?
Telephone Number -
B. Pumping Record
1. Date of Pumping ��0J� ;� I - 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): — --_---- -------. �_
4. Effluent Tee Filter present? ❑ Yes 0,,No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped B
Name Vehicle License Number -��
Wind River Environmental
Company
7. Location where contents were disposed: -
. r.w e
Signature of Hauler--------'-- pd1e.. -- -.�--�
http://www.mass,gov/dep/water/approvals/tSforms.htm#inspect
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