HomeMy WebLinkAboutSeptic Pumping Slip - 602 BOXFORD STREET 8/2/2018 I
Commonwealth of Massachusetts
ITCity/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record f
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 Location:forms / t
Computer,er,t se
only the tab key Address� .�—
to move your North Andover MA 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
,0a
b
Name �—
GA-
Address(if different from location) —'� —..,—_..
City/Town State �.--� 2-io Cc e
Telephone Number ——
B. Pumping Record
1. Date of Pumping ❑_. �- --Date Gallon2. Quantity Pumped: /s
s
3. Type of system: ❑ Cesspool(s) &Septic Tank ❑ Tight Tank
❑ Other(describe): — - -
4. Effluent Tee Filter present? ❑ Yes TNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Sy tdm;
6. Syste P pedy;
'9
f ' `
Nam Vehicle License Number
Wind River Environmental
Company r ( �__❑_
7. Location where QUNt v i dti:
��rVV 1 •
d
Signature of a r ��— Date
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