HomeMy WebLinkAbout- Septic Pumping Slip - 160 FARNUM STREET 6/17/2019 �/�11SJlbid4(C
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Commonwealth of Massachusetts,
A_ System Pumping Record DE1`,`/\R1`1 It I E_'
Form 4
City/Town of NORTH ANDOVE ASSACHUSETTSTOWN OF NOFZ11i ANDOVER
DEP
i
has provided this arm,for use by local Boards of Health. The System Pumping Record must
be submitted to the local Boar a,lth or other approving authority.
A. Facility Informa
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your NoIrth Andover MA
cursor a not City/Town state Zip Code
use the r to
2. System per
Name
Address(if different from location)
City/Town State Zip Code
976 (OV7-
9 7
Telephone Number
B. Pumping Record
'00
1. Date of'Purnping _ . Quantity ' ure
Date Gallons
3. Ty pie of system- E] Cesspool(s) Sepfi Tank Tight Tank
El Other earn
i
t
, . Effluent Tee Filterpresent? s No If yes,was it cleaned? des No
5 Condition System:
M System Pumped
jA
k, ) 1 1(7M
Name Vehicle License Number
Wind River Environmental Havornio wwTp
Company 40 %9 Pofter St,
. 'Location where contents were disposed.
BM&Ord,
Sintw-r f Date
t f rm . # / 3 System Pumping Record f