HomeMy WebLinkAbout- Septic Pumping Slip - 246 CANDLESTICK ROAD 12/10/2018 Commonwealth of MaS achtmett
N - City/Town of NORTH_AND __ER� 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: 1'; ?
When filling out 1. Sysnl�'
Location:
forms or)thecomputer,use4 y1("i le
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:
�s b /l✓ " t
Nam
._....... ----------- --
e xa Address(if different from location)
.,..,...__ _-..--
City/Town State i Zip Code
Telephone Number
B. Pumping Record
17
1. Date of Pumping C7ate - - 2. Quantity Pumped: 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 No5. Condition of System:
6. Syste Prim ed By:
Name Vehicle License Number
Wind River Environ ental
Company
7. Location where contents were disposed:
Signature of Hm " "" Date
http://www.mass.gov/dep/water/approvals/t5forrns.htm#inspect .
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