HomeMy WebLinkAbout- Septic Pumping Slip - 200 RALEIGH TAVERN LANE 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETT
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
i
Important:
When filling out 1. System Location:
forms the op
computer,
r,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:
A
Q
b r4 _._. .._.....
Name
o t i r �a d
Address(if different from to tion)
CityfTown _ State Zip Code
Telephone Number
B. Pumping Record
o .._1 1
1. Date of Pumping to 2. Quantity Pumped: Gallons .............._ _._-
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): _._._. - ....._......
4. Effluent Tee Filter present? ❑ Yes •.- No If yes, was it cleaned? ❑ Yes a
5. Condition of System:
�. - _....._...__ _._ - - -- _-........ ........__...
& System Pumped By:
Name Vehicle Llcensei"
_Wind River Environmental '
.._ S P ov
Company b- radford, Ma 01M
7. Location where contents were disposed:
(4) 374-2382
AL-3r
na re of Hauer Date
http://www.mass.g Me /water/approvals/t5 s.htm#inspect
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