HomeMy WebLinkAboutSeptic Pumping Slip - 107 GRAY STREET 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 15.351.
A. Facility information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Addres /�
to move your
cursor-do not Cilytrown Slate
Zip Code
use the return
key. 2. System Owner:
Name
_ _._.
Address_(if different_from location)
State Zip Code
City(Town
t _ _c !
:re fep one umber —
B. Pumping Record
1. Date of Pumping Date — — 2. Quantity Pumped: Gallons
3. Type of system. ❑ Cesspool(s) ryptft c Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - - -
4. Effluent Tee Filter present? es ❑ No if yes, was it cleaned? es ❑ No
5. Condition of System:
6. System Pumped By:
Wind River Environmental
_ -----
------ 163 Westerlt Ave.
Name Vehicle License Number
--------.. -Glou ter,..MA 01930 -
Company
7. Location where contents were disposed:
Signature
aul
a er �"± Date
Signature of Receiving Facility . Date
arth Arkin,.,,
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