HomeMy WebLinkAbout- Septic Pumping Slip - 66 HAY MEADOW ROAD 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH A6VC1OVE R MASSACHUSETTS
1 _ System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must t
be submitted to the local Board of Flealth or other approving authority. ! >
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A. Facility Information
Important:
When filling out 1, System Location:
forms on the �� /�, // �,�y `/"f f
computer,use E ''_.. .._...._(C.`1 'L"�' lCG°' _.__..._.. / ' .. <, ._. _......._...
only the tab key Address 1
to move your North Andover MA 01845
cursor-do not -_____ _._ _........_..______. ____..__.-------.m_,.
use the return City/Town State Zip Code
key. 2. System Owner:
Name
Address(if different from location) —._.__._..__._.___
City/Town State Zip Code
Telephone Number
8.---Pimping Record
1. Date of Pumping a - -F-- 2. Quantity Pumped: ns
Date Gallons
3. Type of system: ❑ Cesspool(s) [T Septic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present? [ .Yes [] No If yes, was it cleaned? ( .Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License umber
Wind River Environmental
Company
7. Location where contents were disposed:
_.__...._ ._._.._..__ . . ._.....w._ .._......__ _.._......._ ------..
Signature of Hauler date
http:l/www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect
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