HomeMy WebLinkAboutGrease - Septic Pumping Slip - 757 TURNPIKE STREET 3/23/2020 IL
Commonwealth of Massachusetts
City/Town of NORTH AN DOVE R, MASSACHUSETTS
System Pumping Record
Form 4
' M
DEP has provided this form for use by local Boards of Health. The System Pumping etord must
be submitted to the local Board of Health or other approving authority. REG��VfV
A. Facility Information MAR 2 ?,
Important: �OR0H PND.ER
When filling out 1. System Location: , wNOF DEpP(tZME
forms on the
computer,use 75—7 17rYN f�i kP 5�
only the tab key Address
to move your North Andover MA 01845
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
t11 b
Name
Address(if different from location)
City/Town State Zip Code
Y?Q to?'3 � G
Telephone Number
B. Pumping Record
Os-- L —Z 1�G�PG'
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank dr,
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Z'--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:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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