HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 157 OLD CART WAY 10/21/2019 ?,.
4-
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS ��
- System Pumping Record 11?p1g
Forms ` "'7, �
oPrR
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 on the
computer,use l��] fJ t c) c,.r-1— W�y
only the tab key Address
to move your North Andover MA 01845
cursor-do not
use the return City/Tovm State Zip Code
Key.
2. System Owner:
im b C�1S1 ;I�
Name
Address(if different from location)
City/Town State " Zip Code
Ce t -"( fo`7 C5 C3`-1 S
Telephone Number
B. Pumping Record
I � i vd
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [Yes ❑ No If yes, was it cleaned? [[Yes ❑ No
5. Condition of System:
8n/(t, ic.
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental �,
Company — + lI� C'lilb VV e o S
7. Location where contents were disposed: 40 S Porter St
_ Bradford, Ma 0183F
(978) 374-2332
Signature of Hauler Cate
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t5form4.doc•06103 System Pumping Record-Page 1 of 1