HomeMy WebLinkAboutSeptic Pumping Slip - 165 BOSTON STREET 1/19/2016 1�- 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 System Location-
5
forms on thePt
computer,use -
only the tab key Addres
to move your ...,/w1j A
Zip Code
cursor-do not State
use the return City[Town
key. 2. System owner:
Name
Address(if from–location)
a-w---n- State Zip Code
ci�y—/T
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:Date Gallons
3, Type of system: ❑ Cesspool(s) C],,,-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [111flo if yes, was it cleaned? ❑ Yes 91N0
5. Condition of System:
6. System Pumped By.
Wind River Environmental
163 Western AV'L HA06WfWVVTP
------ .- Gjou . .cester,-b"01930 -
Company.- -Haverhill WWTP 40 S Porter St
7. Location wh � SnAqnts werE§jsposed: Bradford, Ma 01835
40 PC
(9 9 -
.df G
Nl
Date
Signature of Auler
Date
Signature of Receiving Facility
15fo(m4.doc•03106 system Pumping Record-Page I of I