HomeMy WebLinkAbout- Septic Pumping Slip - 112 ABBOTT STREET 6/17/2019 Y�f ��IiAlr l�//UIiM ��Y,
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Commonwealth of M
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System Pumping, Record
Form
DEP has provide'' il Form for use by local Boards of Health. The System Pumping Record'must
be s 1W d to the local Board of Health or other approving authority.
A. Facility Inform
Iron :
When fiffing lout 1. System Location:
forms on the
computer,use
lonly the tab fey dr>
to move your North Andover MA 01845
cursor-do not 1
use the return Cit [ wn ,state dip Code
key.
2. System Owner
-I, Name
d
Address i n from to
City/Town State Zip Code
9-7f 7
Telephone Number
R. Pumping Record
goo
1. Date,of Pumping Date _ , Quantity Pumped: Gallon
3. Type of system; Cess ] s, Tank El Tight'dank
El Other(descr'be):
4.
Fluent Tee Filter resent" Yes FrNo Iflyes,was it cleaned? El Yet 0 No
5: Condition of'System:
6., System Pumped E :
A14MN
Name Vehicle License Number
Wind River Environmental
Company
T Location where contents were disposed-
II T
Signatute of Halbl r Date
t6#orrnlet.d -06,103 System Pumping Record! Page 1 of I