HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 STONECLEAVE ROAD 10/21/2019 Commonwealth of Massachusetts
- City/Taws Of NORTH, AND®VER AgSSACHUSETTS
- System Pumping Record
r` Form 4
DEP has provided this form for use by local Boards of Health. The System Pump ng 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 on the I" g — _ - E
computer,use v �gel @ v
only the tab key Address
to move your North Andover _ MA 01845
cursor-return
not City/Town State Zip Code
use the urn p
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code ,
I+
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Purnped: ��-
Date Gallons
3. Type of system: ❑ Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other(describe): -- —
4. Effluent Tee Filter present? ❑ Yes ja-1 o If yes,was it cleaned? ❑ `.yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://vvvvvv.mass.gov/deplwater/approvals/i5forms.ht;.*inspect
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