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HomeMy WebLinkAbout- Septic Pumping Slip - 946 OSGOOD STREET 12/10/2018 Commonwealth of Mas achuc:)etts a City/Town of NORTH AND OVER, MASSACHUSETTS System Pumping Ric-ord 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. ' 1 A. Facility Information Important: When filling out 1. System Location: forms on the . �„. computer,use 11 .t _ 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: ah Ib l/1 r Vyd2� 165 ✓(� Name Address(if different from location) City/Town State ZipCode Telephone Number B. Pumping Rt:cordT--__.___---___.______. 1. Date of Pumping Date 2. Quantity Pumped: Lallans 3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes _ hie If yes, was it cleaned? ❑ Yes El No 5. Condition of System: I 6. System Pumped By: .w Name Vehicle License Number Wind fiver Environmental Company 7. Location where contents were disposed: � � - I ;...SEB" 1.0 __._....__ ... ALL ST- rnl Sol IT KIMB Signature of Hauler We RD r MA http://www.mass.gov/dep/water/approvals/t5forms.htm##insl)ect B AD g71 -37 -7471 1 t5form4.doc•06103 System Pumping Record-Page 1 of 1