HomeMy WebLinkAboutSeptic Pumping Slip - 500 GREAT POND ROAD 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 CHAR 15.351.
A. Facility information
J/'
Important: 1, System Location:
When filling out
forms on the
computer,use
only the tab key Addr)�
to move your
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cursor-do not State Zip Code
use the return
key. 2. System Owr)er:
Av-devell-
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Name "j
Address(if different from location)
State Zip Code
'Te I e-p—ho n'e Number Y_
B. Pumping Record
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1. Date of Pumping 2, Quantity Pumped: Gallons te
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank a'se Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M-No" If yes, was it cleaned? ❑ Yes S;-We
5. Condition of System:
11 a_2
6. System Pumped By:
Wind River Environmental
-Nam-e 1-63 WeAd6AVC Vehide't/tense Number
__.___,G1ou=ftr,_MA.01930_.
_6_0mpany
7. Location where contents were disposed: STEWARTS SEPTIC SERVICE
58-SOUTH-KIMBALLST. -
BRADFORD, MA 0-18351.
Signature of Hauler Date
-§71g-na-l-u-r-e-,-of—Re—ce-i,v-i-ng-$:a—cil'it�—*- -Date-_-_.
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