HomeMy WebLinkAboutSeptic Pumping Slip - 409 FOREST STREET 7/5/2018 Commonwealth mfMassachusetts
C| [l of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record '
Form 4
DEP has provided this form for use bylocal Boards pfHealth. The System Pumping Record must
hesubmitted bothe local Board ofHealth mrother approving authority.
A. Facility Information
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When filling out 1. System Location:
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t^move your North Andover �A 01845
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use the return "'v''"°"' nm�* Zip Code
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2.2. GyntemOwnec
Name
Address(if different from location)
State Zip Code
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B. Pumping PuN0ping Reco,d ----
1. Date ofPumping Dais2� Oumndty9umpad�
Gallons
3. Type ofsystem: El Cesspool(s) 0l Septic Tank El Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? Yes No |fyes,was kcleaned? 0 Yon Fl No
5. Condition oYSystem:
8. System Pumped By:
Name Vehicle License Number
Wind River Environmental
ovmvony '--------------------------'
7. Location where contents were dioponed�
Signature of Hauler Date
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