HomeMy WebLinkAboutSeptic Pumping Slip - 70 RALEIGH TAVERN LANE 8/2/2018 °'Co 'm
�-= Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MA.SSACHUSPTT. �
_ System
Pumping Record
.--.0
Farm 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 fining out 1. System Location:
fo mp the
computer,use ..�_....,_—_ ,G�L�C�_ ._
only the tab key Address ------
to
____Jto move your North Andover
cursor-do not City/Town �� "� _______ _ _ �_._. 41845
use the return State _ Zip Code
—
key,
2. Sy
sm
_�-t-
,.me
r
`p/f4 Address(if different from location)
State s Ve1p Cede
Telephone Number
B. Pumping Record
r A—ZY
6-0
2. Quantity Pumped:1. Date of Pumping gat _.._.__.
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): — --- --
4. Effluent Tee Filter present? Yes ❑ No If yes,was it cleaned? �Yes ❑ No
5, Condition of ystem:
6. Syste ,Pu ped
Name _ Vehic /Cz—leNumber
Wind River Environmental
7. Location where Conten ere disposed:
CJ�• 1
Sature of P Laufer
ignDate
http:/A,vww.mass.gov/dep/Water/approvals/t5forrns.htm#inspe
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