HomeMy WebLinkAbout- Septic Pumping Slip - 224 SUMMER STREET 12/10/2018 Commonwealth of Ma ;Sachu.sotts
uv = = City/Town of NORTH ANDOVER MASSA HUSET'TS
System Pumping Record t
a 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
ti
Important:
When filling out 1. System Location:
forms on the a, t
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:
6,-,-J'
Name
Address(if different from location)
City/Town State Zip Code
_ -r JS _._ -. _..... _ _-7
Telephone Number
B. Pumping Record
1. Date of Pumping lC d� i — 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Gesspool(s) ] Septic Tank ❑ Tight Tank
❑ Other(describe): __..._..._ __..._.._._ __..a.,. _ __ ......
4. Effluent Tee Filter present? Yes [ "No o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
_ ..1 I r -I 'I z 1
Name Vehicle License Number
Wind River Environmental
Company --- --
7. Location where contents were disposed:
------------- ----
Ipswich, MA.
...._..........
_..__ — _ ..w.._.._.._. . .__.... .__.....__.__.
Signature of Hauler Date
http://www.mass,gov/dep/water/approvaIs/t5forms.htrn#inspect
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