HomeMy WebLinkAbout- Septic Pumping Slip - 215 GRANVILLE LANE 1/7/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MAS►SACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must I
be submitted to the local Board of Health or other approving authority.
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A. Facility Information
Important: _
When filling out 1. System Location:
forms on the
computer,use t 7 r C,o,1 4
only the tab key Address
to move your North Andover MA 01845
cursor-do not Cit /l own — _.__.
use the return y Stake Zip Code
key. 2. System Owner:
VQ
Name ——
ream -
Address(if different from location)
_- —
CitylTown State Zip Code
-- ---_.............a_- _
Telephone Number
B. Pumping Record
1. Date of Pumping Date _ 2. Quantity Pumped:
Gallons
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
5. Condition of System:
6. System Pumped By:
ame'^�,..t.i >' Vh(�� ' 1CS 5EpT1C ERN1t�E
C�Wind River Environmental h3 d1$35
Company _ 13SAI)F0R0, MA
7. Location where contents were disposed: 978'3724471
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
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