HomeMy WebLinkAboutSeptic Pumping Slip - 10 JERAD PLACE 8/2/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
-, System Pumping Record
- /r Form 4
DEF' has provided this form for use by local Boards of Health. The System Pumpin Record must
be submitted to the local Board of Health or other approving authorit
A. f=acility Information
Important:
g
computer,
tern out Location:
forms
System
on the 4 ^)
tom utor,use
only the lab key Address —to move your North Andover MA 01845
cursor-do not CI lTown__� _...._.. ___
use the return City/Tom State Zip Code
key. 2. System Owner:
V G113 -b
Name
mm Address(if different from location)
__M_,__
Cit /Town
Y S#ate Zip Code
Telephone Number
B. Pumping Record - --�
1. Date of Pumping 2. Quantity Pumped:
----
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? �1 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:
Signature of Hauler Cate '
a �
http:/Iwww.mass.gov/dep/Water/approvals/t5forrns.htni#inspect
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