HomeMy WebLinkAboutSeptic Pumping Slip - 169 GRAY STREET 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 be 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 I. Syst Location:
forms on the C
computer,use
only the tab key Addre
to move your oa"45-
cursor-do not State Zip Code
use the return CityrTown
key
2. Syst 4)
Name
Address(if different from location)
Zip Code
CitylTown §iale
Telephone Number
B. Pumping Record
1. Date of Pumping 2, Quantity Pumped:
'b'a-te Gallons
3. Type of system: Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe)
4. Effluent Tee Filter present? ❑ Yes [9^N'o if yes, was it cleaned? ❑ Yes L'bje"""
5. Condition of System:
6. System Pumped By,
Wind River Enviromnentai
Name 163 WCAM Ave: Vehicle License Number
-- --GIOUMMP-MA 01930
Company
7. Location where contents were disposed:
G.
�od
0,ve
Sigp Zfe-di Hauler
NO 35
Signature of Receiving Facifit 2 Date
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