HomeMy WebLinkAbout- Septic Pumping Slip - 280 REA STREET 4/17/2019 _ Commonwealth of MassachuSc,tts
p City/�T��vt n ofO "t�l �� D K l �d� ���4C�F�11Js�"�"T�
System Pu.urnpi g Relco d
3 Form 4�� J
1
DE P has provided this form for use by local Boards of Health. The syst ,' 9 Record must
local be submitted to vie cal Board of Health or ether approving autho , ,� � ��
when fining out 1. System Location:
i
forms an the computer,use
only the tab key Address
to move your North Andover MA t71845 cursor-do not —..____,.____._.�_____. __.___.___ _
City/Tov�r� --__..___.__.____._ ._,�
use the return State Zip Code
key. 2. System Owner
Mame
_ Address(if different from lacaticny
CitylTovan St-at E _._..__. Zi Code
Telephone Number
B. PUMPing' Record
1. Data of Pumping oath......._ ._.../.- 2. Quantity Pumped:
Gallons
3. Type of system: J Cesspool(s) Septic Tank Q light Tank
❑ Other(describe):
4. Effluent Tee filter present? C4� Yes No If yes,was it cleaned? 0 Yes Cl No
5. Condition of System:
f
6. System Pumped 6y
Name -` - _ —....u_._-_ —_.._Ense
._iJum Vohicre ber f
Wind River Environmental
l,ompany i
7. Location where contents were disposed:
Signature of Hauler Cate
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t5form4.doc•06/03 System Pumping Record•Page 9 of 1