HomeMy WebLinkAbout- Septic Pumping Slip - 66 SUNSET ROCK ROAD 6/17/2019 jwuD�Vi� IV�9�!1�kD
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Com,monwealth, of Massachusetts
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City/Town of NORT H ANDOVER,
MASSACHUSET
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System
Form 4
. 1
DEP has provided this form for use by local Boards of Health. The System Rumping Record must 1
be submitted the local Board of Health or other approving authority.
A.-Facilutty {
Important:
When filling out 1. S st anon:
forms on the
uterr,use
only the tab 1 Address,
to move your North Andover Mai 0,11845
cursor-do riot
use the-retuirh City/Town State Zip Code
key
2. System Owner,
Name
. 1
x
--
Address(if different from location)
4
m
City1 o State Zip Cody
Telephone Number
B. Pumping Record
NOW
/S
. Date of Purnping t ., Quantity Pumped: Gallons
3. Type of system. Cesspool(s) E],O<pfic'Tank E] Tight Tank
']L Other(describe)®
. cEffluent Tee Filter present? El Yes [AINO If yes,was it cleaned? E] Yes [I No
6. Condition of System:
. System Pumped
Name ew,C 8 pfin r
HAV rr W,WT,P
Wind River Environmental
Company40 S Porter St
". Location where contents were i p ae o Ma 0
35
-
11 eA.
Signature: f Haul Date
t5form,, .. •06�/03 Sat mi Pumping Record Page 1, of 1
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