HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 775 FOREST STREET 10/21/2019 L"\ Commonweafth of Massachusetts REC!-:1VED
City/Town of NORTH ANgOVE , M SSACHUSETTS ' CT 212019
Systern Eijrn-ping Record IUVYNOpNORIHANDOVER
Forvn 4 HEALTH DEPAMMENT
DEP has provided this form for use by local Boards of Health. The System Bumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
comps on the
computer,use
only the tab key Address
to move your North Andover MA 01845
cursor-do return not
ret use the City/Town State Zip Code
key.
2. System Owner:
b 5 q
Name
1t Address(if different from location)
CitylTown State Zip Code
'17b'
Telephone Number
B. Pumping Record
1. Date of Pumping 6 - t 1 2. Quantity Pumped: S
Date Gallons
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other(describe): — - - — ---
4. Effluent Tee Filter present? ❑ Yes CQ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
--6-"Y 55
6. System Pumped By:
&L4-e. �6 Z 5 0
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
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