HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1187 SALEM STREET 12/4/2019 ,1� Commonwealth of Massachusetts
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System Pumping Record
Form
DEP has provided this form for use by local Boards ufHealth. The System Pumping ust
be submitted to the local Board of Health or other approving authority.
A. Facility Information DEC 0 4 2019
Important: TOWN OF NORTH 8NDOVER
When filling out 1. System Location: HEALTH DEPARTMENT
forms onthe )
computer,use 10
only the tab key Address
to move your North Andover MA 01845
cursor Uonot Q��To°m ---------------------'----� _§6����- Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City[Town State p Code
Telephone Number
B. Pumping Record
1. Date of Pumping —"-_—tL+-- 1 2. Quantity Pumped:
Date Gallons
3. Type ofsystem: F� Cesspool(s) KSe[kioTank Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? E] Yea =n~�u |f yes, was \tcleaned? E] Yea E] No
5. Condition ofSystem:
8 SyatamPumpedBy�
� 3 {J
mume ,e,"=License Number
Wind River Environmental
cmpar�
7. Location where contents were disp000d�
Signature mHauler ua,a
http:6/wmvw.massgov/depkwmtar/appnova|s85forma.htm#inapeot
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