HomeMy WebLinkAboutSeptic Pumping Slip - 1801 TURNPIKE 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: j/
When filling out 1. System Location- k
forms on the ( LAL411"
computer,use
only the tab key Add re
to move your / P dpV
cursor-do not Stale Zip Code
use the return
key. 2. System Owoer:
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Name
Address(it different from location)
State Z!p Code
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Telephone Number
B. Pumping Record
3 15-
2. Quantit Pumped:
y
1. Date of Pumping to Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank 'El Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Wind River Environmental
Name 163 WesteRl Ave. Vehicle License Number
-.-.--..-,Gloucester,-bfA.01930...
_6_0mpny
7. Location where contents were disposed:
STEWARTS-SEPTIC SERVICE
58 SOUTH KIMBALL ST.
Signature of Hauler D'a"te" '-BRADFORD$'-MA Q
_§iin_aU_re_'o,_fReceiving Facility * Da-te-
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