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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10/21/2019 Commonwealth of Massachusetts City/Town of NORTH ANDO E g MASSACHUSETTS - - ' System Puffing Record Form 4 'M DEP has provided this form for use by local Boards of Health. The System Pumpang 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 /> SGK only the tab key Address to move your North Andover MA 01845 cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name ' "X-11 Address(if different from location) City/Town J State Zip Code 2-7 6fS.- Telephone Number B. Pumping Record 1. Date of Pumping Date (R 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool($) % Septic Tank ❑ Tight Tank Other(describe): — 4. Effluent Tee Filter present? ❑ Yes �] No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: tAl� 26 ?sue Name Vehicle License Number Wind River Environmental Company 7. Location where contents were disposed: 40 _ _ o Signature of Hauler Da a http://www.mass.gcv/dep/w A ater/approvals/t5forms.ntrnspect (97 f© -, , Ala 0183. t5form4.doc•06/03 System Pumping Record•Page 1 of 1