HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 89 WINDSOR LANE 10/21/2019 Commonwealth of Massachusetts OCT 2 12019
j City/Town City/Town Of NORTH ANDOVE , � ASSACHUSEYTS rn,nq HANDOVER
System Ptimping Record _.
Fern 4
DES" has provided this form for use by local Boards of Health. The System Pumping Reccrd must
be submitted to the local Board of Health or other approving authority.
A. FacHity information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your North Andover VIA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
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Name
' Address(if different from location)
City/Town State Zip Code
4-tg �S 5 01 ,51
Telephone Number
B. Pumping Record
1. Date of Pumping -15-
00
Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) E'rSeptic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes �1 No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Ltljy el °1
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental r
C`�vcEirnlii Vv{fd B t"'"
Company I i 40 S
St
7. Location where contents were dis-osed: Porter
Bradford, Ma 0183.r-
Signature of Hauler _ Date
hftp:/twww.mass.gov/dep/Water/approvals/t5forms.htm#inspect
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