HomeMy WebLinkAboutSeptic Pumping Slip - 2189 TURNPIKE STREET 8/2/2018 Commonwealth of MassachUsetts
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P City/Town of NORTH_ANDOVER, MASSACHUSETTS
System Pumping Record
� g
n !_` Form 4
DEP has provided this form for use by local Boards of Health. The System Pum i cord must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1 '..u.
When
h on Ch out 1. System Location:
f
computer,use �C .�r�l
only the tab key Address
to move your North Andover
cursor-do not 01845 _
use the return City/Town State
key.
2. System Owner:
VQ b
Name
A-1- Address(it different from location) -�` "M —
CitylTown State
Zip Code
Telephone Number --'
B. Pumping Record
1. Date of Pumping—i-� t ` 2. Quantity Pumped:
Gallons
3. Type of system: CJ Cesspool(s) ,,Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company ._.�
7. Location where contents were disposed:
_
W.W.
Signature of Hauler _ Date _ ApSwiC , MA.
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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