HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1620 SALEM STREET 12/4/2019 Commonwealth of Massachusetts
x� City/Town of NORTH ANDOVER, MASSACHUSETT
- Systern Pumping Record
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. RECEWED
A. Facility Information DEC 0 4 2019
Important: TOWN OF NORTH ANDOVER
When filling out 1. S stem Location: HEALTH DEPARTMENT
forms on the r r'
computer,use `�� —_..—...�_. —....
only the tab key Address
to move your North Andover MA — -- 01845
cursor-do not City/Yawn — —" State Zip Code
use the return
key. 2. System Owner: �' )
vas b ► CO A k i,/ Va3 i � &
Name
Address(if different from location)
City/Tawn State Zin t7� Cod
Telephone Number
B. Pumping Record
1. Date of Pumping -----—Date 2• Quantity Pumped. Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YesZ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
on
��1\ti ---- --—.—......--— —_._------.._-- —.
6. System Pumped By:
Name
--- Vehicle License Number
Wind River Environmental
Company -----�..—_--. _.—._
7. Location where contents were disposed:
G.L.S.D.
Signature of Hauler rth Andover, MA.
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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