HomeMy WebLinkAbout- Septic Pumping Slip - 946 OSGOOD STREET 12/10/2018 (3) Commonwealth of Massachusetts
City/Town of NORTH ANDOVETT
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: 1
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address , ; — -
to move your North Andover MA 01846
cursor-do not —..____ ..._-_._ _..�._ _..___._ _—__...
use the return City/Town State Zip,Code
key. 2. System Owner:
rQ b
'�"4°' Address(if different from location) ��—
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CitylTown State Zip Code _....._�__._,..w.._
Telephone Number .___..._..
1
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B. Pumping Ripcord
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1. Date of Pumping pate — - 2. Quantity Pumped: --.--.
Gallons
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3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe): -— —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No
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5. Condition of System:
6. System Pumped By:
11im: .1.._ __. ------_...... _- ._,_.,_
Vehicle License Number
Wind River Environmental
Company
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7, Location where contents were disposed:
_ • -- . m __
Signature of Hauler pate
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
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