HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 946 OSGOOD STREET 3/23/2020 Commonwealth of Massachusetts
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City/Town of NORTH AND ER, 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.
40
A. Facility Information oFN° —
Important:
When filling out 1. System Location: �
forms on the 9 f'
computer,use (� _._.__.......5�� ` _ _
only the tab key Address
to move your North Andover MA 01845
cursor-do not — — --— - -----
use the return City/Town State Zip Code
key. 2. System Owner:
b
Name
Address(if different from location)
City/Town State � J _ 6 7 7 _ Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
jK Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Z SZ ---
_... ......_ ..---- — —_-._-----...--
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/Water/approvalstt5forms.htm#inspect
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