HomeMy WebLinkAboutSeptic Pumping Slip - 65 SPRING HILL ROAD 7/5/2018 Commonwealth of Massachu.%tts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When Ailing out I Syslern L atipn:
forms on the
computer,use G6 00
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return Cily[Town State Zip Code
key.
2. Sy em Owner:
b
Name
Address(it different from location)
d&tyaown —State ZC
Telephone Number
B. Pumping Record
(j
1. Date of Pumping 4—Fr2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) Septic Tank ❑ Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped B
-Name— Ve—h€c—leuoense Number
Wind River Environmental
Company
7. Location where contents were disposed:
rV
Signature of Hauler W; Date
http://www.mass.gov/dep/water/approvals/t5form, * Ap.
14.
yylc 7`�p
t5forM4.doc-06103
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