HomeMy WebLinkAboutSeptic Pumping Slip - 101 CHRISTIAN WAY 1/19/2016 �C-\ Commonwealth of Massachusetts
City/Town of
-- System Pumping Record NORTH ANDOVER
Form 4
r— 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. SysteT Location:
forms on the t "
computer,use
only the tab key Address-
to move your ®�C� ---
_ -
cursor-do not city/Town - Stale Zip Code
use the return
key. 2 System Owner'
_ ire
Name _
_.._
�° Address(if different from location)
City[Town
— State Zip Code
Telephone Number
B. Pumping Record
��� 2. Quantity Pumped: -
1. Date of Pumping Date ��,,. Y P Galtons
3. Type of system. ❑ Cesspool(s) optic Tank E] Tight Tank E] Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E �o If yes, was it cleaned? ❑ Yes Qµloo
5. Condition of System:
6. System Pumped By:
Wind River Environmental
Name Vehicle L'+tense Number
Iou ter,- A 01930_
Company
7. Location where contents were di s dS.
North 6,r 1h In eve "
Signature of Hauler Date
Signature of Receiving Facility Date
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