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HomeMy WebLinkAboutSeptic Pumping Slip - 93 TURNPIKE STREET 7/5/2018 `. Commonwealth of Massachusetts City/Town of NORTH ANDOWER MASSACHUSETTS System Pumping Record Form 4 P g c o DEP has provided this form for use by local Boards of Wealth. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use 'TQ1z' only the tab key Address to move your North Andover MA 01845 cursor-do not Cit !Town use the return y State Zip Code key' 2. System Owner: b Name Address(if different from location) _ — Cityl'I own State � � Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Q'V. 2. Quantity Pumped: Ga ons 3. Type of system: ❑ Cesspool(s) [] Septic Tank ❑ Tight Tank Other(describe): G)(4e 6(3c- Com. t 4. Effluent Tee Filter present? ❑ Yes No if yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: S. System Pumped By: 9���� Name Vehicle License Number Wind River Environmental Company 7. Location where contents were disposed: SEPTIC SERVICE Signature of Mauler -_58 SC}UTN K5�© T' I W%06 http://www.mass.gov/deptwater/approvals/t5forms.htm#inspect BRp►�OR 97$-372-7471 t5form4.dec•06103 System Pumping Record•Page 1 of 1