HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 93 TURNPIKE STREET 3/23/2020 .........._..........__-
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, 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.
2
A. Facility information
Important:
When filling out 1. System Location:
forms on the
computer.use `t �C�j��- /1 — - ...... _.......
_.. ---
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: 4'e—,
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
Other(describe): (�re�S�
4. Effluent Tee Filter present? ❑ Yes [S� No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
I!A/17L q6z s --
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
IN f
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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