HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 271 CANDLESTICK ROAD 12/4/2019 Commonwealth of Massachusetts
-_-; City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
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 ?019
Important: r n-�i ,�Tu ,
1 System Location: T J,,;
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forms on the cy ® � hL raR Ro:-_NT
computer,use —!/--._._. ... _._. —. ._- ... _—.- ........— —only the tab key Address
to move your North Andover MA 01845
cursor-do not ----- -- ------
use the return CitylTown State _ Zip Code
key. 2. System Owner:
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Name
Address(if different from location)
City/Town State Zip Code —
';a 3?75�
TelephiNumber
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) �eptic 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: _
--..— .........
Name Vehicle License Number
Wind River Environmental
..._........-----
Company
7. Location where contents were disposed:
f
Signature of Hauler Date
I'W T'�
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
Ipswich, MA.
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