HomeMy WebLinkAboutSeptic Pumping Slip - 733 TURNPIKE STREET 1/19/2016 (2) �C-\ 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 - — 1�°��` �Ihr
Important: ,
When filling out 1. System Location:
forms on the
5 ---- - -
computer,use '�� I - - -- - -
only the tab key Addres /�__ � p
to move your _ 1 �� 0j8q'S--
cursor-do not GtyfTown State
Zip Code
use the return
key. 2 System Owner:
Name
�°° Address(if different from location)
State Zip Code
Cit w
y/Ton
Telephone Number —
B. Pumping Record
l t ` b 00
1. Date of Pumping -e ------ - 2. Quantity Pumped: -- —
Dat Gallons
3. Type of system. ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ease Trap
❑ Other(describe)
4_ Effluent Tee Filter present? ❑ Yes [L Ndl if yes, was it cleaned? ❑ Yes
i
5. Condition of System: `
6. System Pumped By:
Wind River Environmental
—- Ib3'�Ves Avg:
Name Vehicle License Number
---- _ _tGlouonter,-MA 01930
Company
7. Location where contents were disposed:
T WA RTS SEPTIC SERVICE
58 SOUTH KIMBALL ST;
---- - _ Date RADFC,�RD, MA O O35
Signature of Hauler
978-372974Z1
Signature of Receiving Facility Date
15form4.doc 03/06 System Pumping Record•Page I of t