HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 515 BOSTON STREET 10/21/2019 Commlonweaf$h of Massachuset�s
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System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms 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
key. 2. System Owner: i r
b r�� Y) D vSSG✓)+
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 7— f 7-19 Date2. Quantity Pumped: Gaii
ns
3. Type of system: ❑ Cesspool(s) dseptic Tank ❑ Tight Tank
❑ Other(describe): — — ----
4. Effluent Tee Filter present? ❑ Yes ZNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: Y�
`'jQ `� v
6. System Pumped By:
Name VehicidAILM900~0 VVVVI t
Wind River Environmental 40 S Porter St
Company
7. Location where contents were disposed: Bradford, Ma 0188�
(978) 874-2382
r _
Signature of Hauler Date
hftp:/Aqww.mass.gov/dep/Water/approvals/t5forms.htm#inspeek
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