HomeMy WebLinkAbout- Septic Pumping Slip - 107 GRAY STREET 12/10/2018 Commonwealth of Massachusetts
._. City/Town of NORTH ANDOVER, MAS ACHUSETT
w` n 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 on the may./ .
computer, use
c.�
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:
rob b �o ---------
Name.,
Address if different from loeatio p —
City/Town State �J ".�-ip Code
Telephone Number
B. Pumping Record _-
1. Date of Pumping __ .._...__.. ------— 2. Quantity Pumped: ---- --
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): ______...___.... __.__._.__.
4. Effluent Tee Filter present? El Yes ❑ No If yes, was it cleaned? .- Yes ❑ No
5. Condition of System:
1
6. System Pumped By:
r
ame Vehicle LicrpNylbor
� v t"
Wind River Environmental U
-Cm`-P"'------'- � Porter
Company St
7. Location where contents were disposed: Bradford, Ma 018,,31," I
� _ .xw �_..._....__...
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Ye of Ha ter Date
http://www.mass.ater/approvals/aerms.htm#inspect
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