HomeMy WebLinkAbout- Septic Pumping Slip - 83 ACADEMY ROAD 10/3/2018 U
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Commonwealth of Massachw3etts (1 f 3018
City/Town of NORTH ANDOVER MASSACHUSETTS,
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:
When filling out 1. System Location:
forms on the
' A computer,use
only the tab key -,i�d � 3 c,,dress
to move your North Andover MA 01845
cursor-do not
use the return City/Town State Zip Code
key, 2, System Owner:
4"J iii --.—
Name
G.—M Address(if different from location)
State Zip Code
Teleq.7
phone rJumoer
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: M Cesspool(s) JX Septic Tank El Tight Tank
El Other(describe): -------- ----—---
4. Effluent Tee Filter present? n Yes No If yes,was it cleaned? 0 Yes El No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: i-IOU(M)l
Bradford.-W
§7,g—nat.r.of
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http://vvww.mass.gov/d n#Ushttp://www,mass.gov/d�ep/water/apprct 2382�dld—t' 11374
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-'radford fWa 0183,
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
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