HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 81 CHRISTIAN WAY 10/21/2019 Commonwealth of Massachusetts
C€tyffo n of NORTH A DOVER, MASSACHUSETTS
. System Pumping Record
Form 4
h4
DEP has provided this form for use by local Hoards of Health. The System Pumpng Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. Syst✓m Location:
forms the , f s
computer,use � I
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:
«� b Di—i V e
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ' � 2. Quantity Pumped: -'
Date Gallons
3. Type of system: ❑ Cesspool(s) �'`'`eptic Tank ❑ Tight Tank.
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes [J-Nc If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
A,g.0 Ljf 9, -� t` 1
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents .were disposed: Haver m WWTP
40 S Porter St
Bradford, Ma 41 M
fgWyni
Signature of Hauler Date
hftp:/Avww.mass.gov/dep/water/approvals/t5forms.htm#inspect
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