HomeMy WebLinkAbout- Septic Pumping Slip - 10/21/2019 Commonwealth Of Massachusetts
C'Ity/Town of NORTH A U_ VE , �MASSACHUSETTS
System Pumping �Record - ----
Fe rrn 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 on the
computer,use 3 S (3r Wes.�iz r 5d'
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town/Town
use the return tY State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ~i e1 2. Quantity Pumped: 0
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
El Other(describe): _�/ -- — ---- - --
4. Effluent Tee Filter present? ❑ Yes L7 No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
�)1P 1c; — i 'ZI
Name Vehicle License Number
Wind River Environmental Company - — I.W.W.iT
.p
7. Location where contents were disposed: Ipswidn' N1 1.
Signature of Hauler Date
hftp://www.mass.govi'dep/water/approvals/t5forms.htm#inspect
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