HomeMy WebLinkAbout- Septic Pumping Slip - 224 SALEM STREET 12/10/2018 Commonwealth of Massachusetts
--
x City/Town of NOR V 9 MASSACHUSETTS
aSystem Pumping ecor
Form 4
DEP has provided this form for use by local Boards of Wealth. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility lnformation --
I '
Important: �
When filling out 1. System Location: '
forms on the
computer,use
------ l,_, __.....__�._.____. _._._._
only the tab key Address -�� ��� E i
to move your North Andover MA 01845
cursor-do not ___ _ __.._. _,... _.
use the return ity/Town State Zip Code
key.
2. System Owner:
t�
_b_ /° � ° ,
Name �,
4
Address(if different from location)
L/
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �f C
17ate -�.�� 2. Quantity Pumped: !' }
Gallons
3. Type of system: ❑ Cesspool(s) Z Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q No If yes, was it cleaned? ❑ Yes Defro
5. Condition of System:
0l =
6. System Pumped By:
a0-Name Vehicle License Number
Wind River Environmental ++�
Company ----___........_._.._ a.�'.L.
7. Location where contents were disposed: North Andover, MA,
5-
0
Si 0
Si a re of Hauler date —.-._._ __._...._...
http:f/www.mass.gov /water/approvals/t5forms.htm#inspect
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