HomeMy WebLinkAboutSeptic Pumping Slip - 151 OLYMPIC LANE 1/19/2016 Commonwealth of Massachusetts
City/Town of
- System Pumping ReGord 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 Addre ^-
to move your n ?�t/ _ ,/ r _ .0 is ---
cursor-do not CitylTown Stale Zip Code
use the return
keys�----� 2. System Owraer:
--
�^ Address(if different from location)
-- .. Stale Zip Code
Teiephone Number
B. Pumping Record
-- .—®" 2. Quantity umped: � }
1. Date of Pumping pate y Ga111Sns
o
3. Type of system: ❑ Cesspool(s) 0--Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): _ __ . __.
— --
4. Effluent Tee Filter present? ❑ Yes ,-f�lo"" if yes, was it cleaned? ❑ Yes ❑ No
5. Condit' of Sy em:
L
IP' i�,tj,
6. Systei umped By:
Wind River Environmental
Name 163 WeitCfll Aver V icletLicense Number
- -.--..-,G10 ter,_Y4MA.QL93Q- __....
Company
7. Location where contents were disposed:
i ature of Hauler Date
Signature of Receiving Facility Oate
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