HomeMy WebLinkAboutSeptic Pumping Slip - 42 WINDKIST FARM ROAD 12/15/2015 \ I,
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Commonwealth of Massachusettsm
of NORTH ANDOVER
City/Town
System Pumping Kecord I
Form 4 M*1 OF NURTH ANDOVER
HEALTH OEPAF�'G"A EN'
DEP has provided this form for use by local Boards of Health. Other for a d,
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 1. System Location: 1` ,r✓
forms on the , (nom 'Mtn ,` �"*w._.4�a c:, w
computer,use ---K ---only the tab key Address .,..
to move your A r pry (tj
cursor-do not y - — -- State Zip Code
use the return City/Town
key. 2. System Owner:
Name
Address(if different from location)
— ---- --- — -- ( M. o
State 'i P C G e _
City/Town A „
Telephone Number
B. Pumping Record
1. Date of Pumping Date — t 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ---
4. Effluent Tee Filter present? ❑ Yes ®" No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System.
6. System Pumped By —
Name r Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Haule Date
r
Signature of Receiving Facility Date
t5form4.doc-03106 System Pumping Record•Page 1 of 1
i
Form 4-_ System Pumping Record
Commonwealth of Mossacwsotss
NossaftsetPs F."
[
RECEIVED
ssem pppr sg2 d JUL
0
TOWN OF NORTH ANDOVER
TOWN OF NORTH ANDOVER
System Owner system
' &d P NrI.vt yi
PW a
4tr. f
4 siYV : ,,% r! 6 "i
Cesspool: trio yes Septic tars W !✓es
Idu4e of
Pumping. LL I Quantity pee d: a C (} Calipers
System Pumped By: Wind River EnWrohloefital, UC Permit
t
Contents transferred to:
i
Contents Disposed at:
ku
L Pu Sign tur :
V
Condition of System/Other Comments
IDep Approved Farm - 12/07/95
I
Commonwealth of Massachusetts
R " i D
City/Town of
System u in eo®rd �
Form 4
DEP has provided this form fqr use by local Boards of Health. Other forms ay
its forrho �
information must be substantially the same as that provided here. Before us
local Board of Health to determine p °igtauhny png bsubmitted to
the local Board of Health o � prfl ntot The
th n 14 days from the pumping date
accordance with 310 CMR 15.351.
A. Facility information
Important: 1 System Location: ( 1
When filling out Y
forms on the ❑. t, _. ---._ `.. -
computer,use
only the lab key Address rs�1
to move your __ ! ./ Gr f � Zip Code
i
cursor-do not - State
use the return
City/Town
key. 2. System Owner:
Name
-------------------
Address(if different fror r location)
_
State
ip Code
Cityrrown
Telephone Number B. Pumping Record
1. Date of Pumping Date 2, Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ ,Septic Tank ❑ Tight Tank ❑
Grease Trap
❑ Other(describe): -- - - -. --
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
A/ �' � *� _
.m Vehicle License Number
ompany
d
o
7. Location where contents were disposed:
� d
_
i t Haul Date
nature of Receiving Facility Date
System Pumping Record•Page 1 of 1
l5form4.doc•03/06
52 ®.