HomeMy WebLinkAbout- Septic Pumping Slip - 1483 SALEM STREET 6/17/2019 E
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City/T own of NORTH w ryv i
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System
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted the local Beard of Health or other approving authority'.
1
A.
I
Facilityit
Important:
When fillinig out 1. System"Location:
forms the
computer,use
only the t bb key Address
to moveyour North Andover MA 01845
cursor- not
the rat City/Town State dip Code
use2. System Owner*
Y; Name
r � r
Address 0f different from tion
City/Town Stag Zip Code
yAky
Telephone Number
B.. Pumping: Record
. Date of PumpingDate, 2, Quantity a Gallons
3. Type s s m: Cesspool(s) P5 Septic Tank El Tight Teak
Other sciW m..a .. _u_ M. .mm... ,, ..�..�.
. Effluent Tee Filter presents El Yes If yes,was it cleaned? Yes Ej No
5, Condition of System:
t
1
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M System Plumped By:
6 ?z5:D
Name Vehicle License Number
Wind River Environmental
Company
7. Lolicati n where contents wereA is lse : avernill VMTP
� Po At
3radford,
Signature of Hauler Date ' "7 � '1.' „
ss.go i p w, ter a r is t5 sw m#inspect
t fora . o • 1 3 System Pumping Record-Page I of I
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