HomeMy WebLinkAbout- Septic Pumping Slip - 12/10/2018 e
Commonwealth of Massachusetts
' ANDOVER, 11MASSACHUSETTS City/Town of NORTH
System Purnping Rekcordl
Form 4
DEP has provided this form for use by local k3r.)ards of Health. The System Pumping Record must
be submitted to-the local Board of Health or other approving authority.
A. FacHity Information
Important:
When filling out 1. System Location:
forms on the
computer,use 315 Turnpike Street
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return City/Town State Zip Cod
key,
2. System Owner:
Lifecyc,le Renewables-Merrimack College
Name
P.O.Box 1144
------------
Address(if different from location)
Marblehead MA 01945
City/Town State Zip Code
(617)304-6.575
Telephone Number
B. Pumping Reacord
11/,!1/1 t"k 9000
1. Date of Pumping 2. Quantity Pumped:
[late Gallons
3. Type of system: El Cess'pool(s) F-1 Tight Tank
&3ptic'rank
Groaso'fank
Other(describe): --------
4. Effluent Teo Filter present?
D Yes [O] No if yes, was it cleaned? Yes No
5. Condition of:System:
OK
------------------
6. System Purnp(.-A By:
Alex M. 0f VA KA
SER vICE
Name TONN, PA IM;BIII *
Wind River Environmental
5-8-SC)UT
SRADFOSI), MAM835
7. Location whero�cont.ents were disposed: 97s-372-747'
:4 natu of Hauler Date
http://www.rriiiss.gov/dep/water/api)rovals/t5fc)rtns.htrn-,,'kispe(.',t
t5form4.doc-06/03 System Pumping Record-Page 1 of 1