HomeMy WebLinkAboutSeptic Pumping Slip - 120 WINDKIST FARM ROAD 1/19/2016 � Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
0 Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, ut 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 Add
to move your
P .
,,
cursor-do not State Zip Code
use the return
key. 2. System Owner:
Name
different from-1location)
c Fty7roWn State Zip Code
Telephone—Nurnti—er
B. Pumping Record
1, Date of Pumping 2, Quantity Pumped: yGilorls
Date
3. Type of system: Cesspool(s) E�ZepVc Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2-_N�o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
1piwicho
6. System Pumped By:
Wind River Environmental 6
Name 163 WeAft AWC ' - ---- -- - Vehicle_License Number
_01oumterp-M.01930
Company
7. Location where contents were disposed:
Sig ure of 57—
Hauler Date
-§�l-g--na—l-'u-re-'of—Receiving—Facility" Date
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