HomeMy WebLinkAboutSeptic Pumping Slip - 35 MARIAN DRIVE 7/5/2018 Commonwealth of Massachusetts
City/Town own of NORTHANDOVER,.MASSA,CHU
SETTS
-- System Pumping Record
a` 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 filling out 1. System LQcation:
forma the fy
computer,use ✓ _VL (IiL _
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 Own
A ISI h --—
Name
Address(if different from location)
C_ . —St
dilly/Tow, __-- — -__ �— Slate ,Zip
Telephone Number
B. Pumping Record �
1. Date of Pumping Date f 2, Quantity Pumped: Gallons���
3. Type of system: ❑ Cesspool(s) [Aeptic Tank ❑ Tight Tank
❑ Other(describe): -- —
4. Effluent Tee Filter present? Yes ❑ No If yes,was it cleaned? Yes ❑ No
5. Condition of�Stam:
6. System P m ed B .
Name Vehicle Licimse Number
Wind River Environmental
Company
7. Location where contents w disposed: i
ach,�A•
Signal of Hauer Date ry p
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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