HomeMy WebLinkAboutSeptic Pumping Slip - 131 CRICKET LANE 9/29/2015 Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must b e submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351,
A. Facility Information
Important:
When filling out 1. System Location-,
forms on the
computer,use C
only the tab key Address-
to move your -V
-- 1-1--Ardov-eR - . - - -... .-II/
cursor-do not CityrTown Stale Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
CityrTown State G"', Zip Code
05-
Telephone Number
B. Pumping Record
I- Date of Pumping Date 2, Quantity Pumped: Gauons 3. Type of system: ❑ Cesspool(s) EU,Se--ptjc Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [;J- If yes, was it cleaned? ❑ Yes [dlila-
5. Condition of System:
6. System Pumped By:
Wind River EnvimmIncutal
-A Vehicle Lice rise Number
Name 163 Vftstern vC
-Gloumter,-MA01930.
6o—mpany
7. Location where contents were disposed:
i�
gni u6 of Hauler 'Date
"
Signature of Receiving Facility NoAeMdMer, MA
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