HomeMy WebLinkAboutSeptic Pumping Slip - 10 CROSSBOW LANE 7/5/2018 Commonwealth of Massachusetts
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~, lV/ | [>wO of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use hylocal Boards qfHealth. The System Pumping Record must
bmsubmitted tuthe local Board mfHealth orother approving authwd4.
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A, Facility Information
When filling 1. System Location:
forms on the
only the lab key Address
o move your North Andover MA 01845
cursor do not ------__-
use the mmm ~y''~~' State Zip Code
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2. GyotmmC>
--'
Name
Address(if different from location) We
--
o1��Tmwn ----'----'—'--- -----------
Telephone Number
B. Pumping Record
1. DateofPumping
2. Quantity Pumped:
Date Gallons
8. Type oYsystem, R Cesspool(s) R 8epUuTenk [] Tight Tank
E] Other(describe): -------------
4. Effluent Tee Filter present? [] Yes No |fyes,was |tcleaned? Yeo Fl No
5. Condition ofSystem:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date 10
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