HomeMy WebLinkAbout- Septic Pumping Slip - 75 FOREST STREET 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVE MASSACHUSETTS
R,-
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 "4
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return CityfTown State Z'ip Code
key.
2. System Owner:
b
VQ
Name
P'P-,e 5
-Address"(-!f different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) Septic Tank El Tight Tank
0 Other(describe):
4. Effluent Tee Filter present? n Yes E-�No— If yes, was it cleaned? ❑ Yes tj---N—o'
5. Condition of System:
6. System Pumped B
1`3
Name Vehicle License Number
Wind River Environmental
j IQ TCompany
, W9 I im 0 W
40 S Porter St
7. Location where contents were disposed:
Bradford, Ma 01835
na re of auler Date
http://www.mass./V/d /wat /approvals orms.htm#inspect
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