HomeMy WebLinkAboutSeptic Pumping Slip - 157 LIBERTY STREET 5/21/2018 RECEJVED
Commonwealth nfK8assachW.,,�Iefts
��'f*/�- f AT
�E��m��`^~--�
City/Town
System Pumping Record �
Form
DEP has provided this form for use bylocal Boards pfHealth. The ' Pumping Record rnust
basubm|�edbothe local Board ofHealth urother approving authority.
—
|mvv*wm' A. Facility Information
When filling out 1. System Location,
forms oil the
computer,use
only the tab key xuunso
mmove your North Andover '
cvmor'uvnot
�u 81846
use the return City/Town State Zip Code —
ken'
_ System
Name
State �ipiCocle�,/�
Co�rwxn��— ------------------------ — --
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
.��`
3. Type ofsystem: El Cesspool(s) ��\SapUoTank Fl Tight Tank
El Other(describe): ---
4. Effluent Tee Filter present? Fl Yeo No |fyes,was |tcleaned? [] Yon [l No
5. Condition o8sm:
G. System
Name
V—eh—icteEtce—,se Number
Wind River Environment AV-
-'al 4 & Vt
Z-Ompa—ny 0'
7. Location where contents W
-96—naiur —a,4uie Date
hthp://vmom.mese.qo�depkmate�eppmva|s/t5forma,htm#|napoo1
mm,mw.uoc`mnmn
System Pumping Record'Page 1v,1