HomeMy WebLinkAbout- Septic Pumping Slip - 300 FOSTER STREET 6/17/2019 0'0 V,
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Commonwe"alth of' Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
aSystem
Form
DEP has provided this form for use by local Boards of Health. The System Pumping,Record must
,
submitted the local' Board ofHealth or other approvilng authority'.
X, Facility Inform
Important,
When filling out 1. S stern Location.
forms on the
computer,use
only the tab,key Address
to move your forth Andover MA 0 1845
cursor-do not
use the return n �CitylTown State Zip Code
y. 2. Owner;
a�
Systern
Name
Address(if different from location
City/Tom Stag i ode
led
Telephone Number
B. Pumping Record
3 ..
. Date of 1 m i g 2. Quantity a pe . �
Date Gallons
3, Type system; El Cis Fight Tank
�
Other(describe):
i
4. Effluent Tee Filter present? No Ides,was it cleaned? El Yes E; No
I
5. Condition of'System.-
6. Ssn Pumped
Name Vehicle Livens Number
'Wind River Environmental
oompany
7. Location where contents were disposed1161 ,
{ 04m '
Signature,of Hauler A4
t �* . ass. r a r l's t5 rms tin it
t5# r wd a 6/0 �Andol,
"� System Pumping Record'*Page 1 of 1;