HomeMy WebLinkAboutSeptic Pumping Slip - 94 GRANVILLE LANE 7/5/2018 Commonwealth nfMassachusetts
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~�Ky/ | owO of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record ��--
Fornn 4
DEP has provided this form for use bylocal Boards ofHealth. The System Pumping Record must
bmsubmitted tothe local Board u[Health wrother approving authority.
A. Facility Information
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When filling out 1. System Locati
forms on the
computer.use LAl
only(he tab key A d 8re ' — ----'
mmove your
North Andover MA 01845
cursor'uonot
use the return ~'»~'ow'
State Zip Code
key- 2. System
Ark"M
Name
Address(if different ffom location)
T��f�°,-----'-'-----�-----------��---- State
phone Number
B. Pumping Record
Date of Pumping Date 2. Quantity Pumped:
Gallons
8. Type ofsystem: E] Ceoapuu)(o) 08opUuTank [] Tight Tank
LJ Other(describe):
4. Effluent Te*Filter present? [] Yeo K No If yes,was it o|omnod? Fl Yea Fl No
5. Condition �
u pdedy:
. System_
N4ame Vehicle License Number
Wind River Envlro,�,entl Y'
Company
7. Location where contents wer
0 Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#insl)e
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� System Pumping Record`Page 1mI