HomeMy WebLinkAboutSeptic Pumping Slip - 295 CANDLESTICK ROAD 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 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 15.3511
A. Facility information
Important:
When filling outSystem Location".
L
forms on(he 'rJ
C"
computer,use
only the tab key Addre
to move your
-do not Zip Code
cursor cty4 State
use the return
key. 2. System owner:
Name
Address
different r:;m location)
CityfT'own State ode
ZIP- ,�c.'
Telephone� Nurnl3W
B. Pumping Record
2-
1. DaleofPumping -_ Y . 2. Quantity Pumpecl� a
Date c�alions
3. Type of system: ❑ Cesspool(s) [04optic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe)
4. Effluent Tee Filter present? L-1 Yes E1,4`8 If yes, was it cleaned? ❑ Yes aJ,,`Ko
5. Condition of Syste
6. System Pumped By:
Wind River Environmental
Name 163 Weitern Alit 1�ehicle License Number
_... _Gloumta,MA 01930.
Company
7. Location where contents were disposed:
signature of Hauler Date
4-MA!- '
Signature of Receivi —Date vagrm-Not,
15toim4 doc.03/06 System Pumping Record•Page I of I