HomeMy WebLinkAboutSeptic Pumping Slip - 90 LACY STREET 1/19/2016 Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
h
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 1. System Location:
forms on the f„:"' .
computer,use _. --- - --
only the tab key Addre
to move your _� �./�i►►N! � � _ f .—.
cursor-do not CityfTown " - - _._...._ _-.- State Zip Code
use the return
key. 2. System Owner.
Name t�
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping — 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ep_Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Na If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Wind River Environmental
Name 16 CStCrn AVC. VehicleiLicense Number
-- _.�G1oUCeSter,_MA.01930 . ._--- _
Company
7. Location where contents were disposed:
Signature of Hauler Date ,
Signature of Receiving Facility Date
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