HomeMy WebLinkAbout- Septic Pumping Slip - 315 SOUTH BRADFORD STREET 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, 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:
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
2. System Owner:
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---5m6 A k ejqltl
VQ Name
different from local'Address(if di o" )—-----------
'67h�y—/Town --- State Zip Code
ej
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped:
Gallons
3. Type of system: 0 Cesspool(s) Septic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes IVo If yes, was it cleaned? n Yes E] Na
5. Condition of System:
6. System Pumped By:
Name Vehicl se Number
Wind River Environmental PIAV
Company 40 $
POrter St
7. Loc o where ntents w r disposed: 'Bradlord, Ma 0183�
(978)-.,M,
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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