HomeMy WebLinkAbout- Septic Pumping Slip - 646 FOSTER STREET 12/10/2018 Commonwealth of Massachut.,etts
City/Town of NORTH ANIDOVER, MASSACHUSETTS
System Pumping Rc;ord�._�
y 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. System Location:
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:
C
�m _ Name 1 ttI( � I
Address(if different from location)
.......... .. .._
City/Town State Zip Code
Telephone Number
B. PItI'Ylpifig R13Cdrd — �_—
t_�?
1. Gate of Pumping 2. Quantity Pumped: .__.._ _._.__..... .._____....__..
dale Gallons
3. Type of system: ❑ Cesspoal(s) [ eptic Tank ❑ Tight Tank
❑ Other(describe): _ --__..............
4. Effluent Tee Filter present? ❑ Yes ['No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
VC/44 Ch
6. System Pumped By:
__.____._..._ _.........___.__ ----_---____----__
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contends
Bradford, Ma 01835
Sugnature of Hauler � — date
http://www.rnass.gov/dep/water/approvals/ orms.hl" #inspec
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