HomeMy WebLinkAbout- Septic Pumping Slip - 445 FOREST STREET 12/10/2018 Commonwealth of fl/lassachw-3etts
City/Town of NORTH AN DOVE, MASSACHUSETTS
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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: o"
When filling out 1. S stern Locatioa
forms on the
computer,use
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:
V Q----
b
Name
Address 6f different from location)
City/lawn State tp(ode
Telephone Number
B. Pumping Record
ZI �d. W
1. Date of Pumping DateORI — _'.r---- 2. Quantity Pumped: daltans
3. Type of system: ❑ Cesspool(s) [] Septic Tank ❑ Tight Tank
Other(describe): - -—
4. Effluent Tee Filter present? Yes [] No If yes, was it cleaned? K Yes No
5. Condition of System:
6. System Pumped By
_._.._.._. � I
....__.__._ . ..___._.____._....._._
Name VEahicle iconse Number
Wind River Environmental
Company
7. Location where contents were disposed:
,I
f
Signature of Hauler ardtgordi
http://www.mass.gov/dep/water/approvals/t5forrns.htrn#insl)ect
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