HomeMy WebLinkAboutSeptic Pumping Slip - 1507 SALEM STREET 7/5/2018 Commonwealth rfMassachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use hylocal Boards ofHealth. The ' tennpwmpingReoonJmomt
besubmitted tothe local Board ofHealth mrother approving authority.
A. Facility Information
Important:
When filling out System Location,
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computer,use
only the tab key pmomso -----'
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2. System
Name '------------ ----
Address(it different Tfmmlocation)
-----------
Telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
3. Type ofsystem: [] Cesspool(s) Septic Tank [] Tight Tank
LJ Other(describe): -----------'
4. Effluent Tee Filter present? Fl Yes No |fyes,was hcleaned? [] Yea No
5. Condition ofSystem:
6. System 8yuhnmPumped By:
Name Vehicle License Number
Wind River Environmental
ovmpmny -------
7. Location where contents were disposed:
Signature of Hauler Nor-thJknd0Ve4A1A-
Date
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t6fvnn4-duc-06103
System Pumping Record`Page 1mI