HomeMy WebLinkAboutSeptic Pumping Slip - 25 JERAD PLACE 1/19/2016 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 substantiatly 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
2,5_
computer,use
only the tab key Address
cursor-do not Jr d P V_
io move your IV /
I- State Zip Code
use the return City/Town
key. 2. System Owner:
Name
_Address_(C(different from-location}
_
CityFrown State Zip Code
Telephone Number
B. Pumping Record
1.( 7' -q- '71 rL 2. Quantity Pumped:
1. Date of Pumping bate Gallons
3. Type of system: ❑ Cesspool(s) P-i5-e_ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe)
4. Effluent Tee Filter present? ❑ Yes EP-1 o If yes, was it cleaned? ❑ Yes [U—No"
5. Condition of System:
J,
6. System Pumped By:
Wind River Environmental
Name Vehicle License Number
_-GIOUCester.-MA01930
-Company
7. Location where contents were disposed:
Signature of Hauler Date 4
P-P
Signature-o-_fReceiving Facility , Date
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