HomeMy WebLinkAbout- Septic Pumping Slip - 315 SOUTH BRADFORD STREET 6/17/2019 Rib �����rmemra", «��
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City/Town of' NORTH ANDOVER,,, MASSACHUSETTSOWI�10F Iq OR f 11 A,NL)(,,.)VlER
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., System
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w4' IForm 4
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DEP has provided this form for use by local Boards of Health. The System Puy ig Record'must
e submitted to the w 'Board of Healthr other approving a rl
A, Facility Information
Important:
When,filling out . System Location:
farms on the
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do not
City/Town State Zip Code
use the return
2. System Owner.
1„
b
f'
�r Name
Dr
r
Address(if different irr location)
City/Town State Zip Code
-7
Telephone Number
B,, Pumping Record
1. Date of Pumping 2. QuantityPumped:
FateGallons
3. Type of system- Cesspool(s) [I Septic Teak El T'ght'Tank
Other0 (describe):
. Effluent Tee;Filter present' Yes No if yes,was it cleaned? Yes
5. Condition System:
t
;
6., System Pumped :
Name Vehicle License Number
i
Wind River Environmental
'+ n
i
". Location where contents were disposed- I,WWT
1PSWI
Signature of Hader date
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forr4. -06/03 System Pumping Record Page 1 of 1