HomeMy WebLinkAboutGrease - Septic Pumping Slip - 315 SOUTH BRADFORD STREET 12/4/2019 Commonwealth of Massachusetts
dCity/Town of NORTH ANDOVER, MASSACHUSETTS
ay 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.R E(�I--"a'--�rk-L i)
A. Facility Information DEC 0 4 2019
Important:
When filling out 1. System Location: TOWN OF NORTH ANDOVER
forms on the
computer.use I ' HEALTH DEPARTMENT
__3 , d .........
----------- m
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town ------------------------------- ---------.....
use the returnState Zip Code
key. 2. System Owner:
V_011 b sz�&Xq
Name
Address(if different from location)
City/Town State Zip Code
6
Telephone Number
B. Pumping Record
1. Date of Pumping -Date
..................... 2. Quantity Pumped.-
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
0 Other(describe): 6_��e 5 e-
4. Effluent Tee Filter present? 0 Yes [9 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle Licen e Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htrn#inspect
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