HomeMy WebLinkAbout- Septic Pumping Slip - 1055 SALEM STREET 10/3/2018 s Commonwealth of Massachusetts 0 3 2018
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City/Town of NORTH JDOVE;t M,tA3 ACHUSETT u°�ii L rri
System Pumping Record
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:
Mien filling cut 1. System Location,
forms on the / ,. --
computer,use . f��_ ,_.._ __
only the tab key Address
to move your North Andover
cursor-do not - -- ___ MA Q1 E345
use the return City/Town State Zip Code -
key.
2. System Owner:
Q j
Name
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Address(if differenk from location)
-.__
ZipC�ade-
41one Nurnber
B. Pumping Record
1. Date of Pumping Date ��� Quantity Pumped;
Gallons
3. Type of system: ❑ Cesspool(s) 0,Septic Tank ❑ Tight Tank
❑ Other(describe);
4. Effluent Tee Filter present? ❑ Yes [X4 No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: t
5. System Pumped By:
Name
Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
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Signaturo_of.-Hauler Date --
http://www.mass.gov/dep/water/approvals/ ,. ° �,
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