HomeMy WebLinkAboutGrease Tank - Septic Pumping Slip - 500 GREAT POND ROAD 10/21/2019 Commonwealth of Massachusetts
CFt ��Tov n of NORTH ANDOVER, ASSACHUSETTS
System Purrnping Record -----
�� Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitleu to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the I �-_
computer,use �/3�1/ _
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zip Code
use the return R
key. 2. System
/Owner
b �V VVCA Wl.'1 - .
Name
Address(if different from location)
City/Town State 7 Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 7 °� 2. Quantity Pumped: x�
Date 6 a sc— Gallons
3. Type of system: ❑ Cesspool(s) ( Sep4t Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
C,c�dl'(Clyt5
6. System Pumped By:
76Z s�
Name Vehicle License Number
Wind River Environmental
Company
7. location where contents were disposed:
_ SEPTfGSERVICE_
3RADF0RD; IWA
Signature of Hauler n7 72_1 71
hftp:/Avww.mass.gov/dep/water/approvals/t5forms.hfi—,#jnspec',
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