HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 111 CAMPBELL ROAD 12/4/2019 .......__._..
Commonwealth of Massachusetts
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City/Town of NORTH AND OVER, MASSACHUSETTS
Ems; System Pumping Record
�S� Form 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. RECEIVED
A. Facility Information DEC 0 4 2019
Important:
When filling out 1. System Location: TOWN OF NORTH ANDOVER
forms on the f HEALTH DEPARTMENT
computer,use ---...�-1�....._.__.._..[ � .. --
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:
t b �In
Name
Address(if different from location)
City/Town State / t Zip Code
l \ �—
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Q tity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes U44o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of f Systemi
6. System Pump
Name Vehicle-L h E Number
Wind River Environmental
-........
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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