HomeMy WebLinkAboutimage (3) .� Commonwealth of Massachusetts
city own 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 substarltially the seme 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 QMR 1 5.351.
A. Facility information
Imporunk:
wnen Titling out 1. System Location:
forms on the
computer,use
arty the ka>5 key
ro moue your
cursor,do not Ciiy/Town ! State Zip Code
uSe the return
Key. 2. System Owr]ar:
�. i O
+++� AddreSS(ff different from 1pCatiorrJ -- ---. y, ._ .
- —. —... _..... Zip--
_,- Code
CityrTawn Stara
Teleprione Number
B. pumping Izecord
1. [date of Pumping at .� __. ......�.__ 2. Quantity Pumped: �aaltosts
3. Type of system: Cesspools) Sgptic Tank [D Fight Tank Z.erease Trap
El Other(describe);
4. Effluent Tae Filter present? 0 Yes 3r11O if yes, was it cleaned? 0 Yes Q-No
5. Condition of System: u
6. System Pumped By:
Wind RiM EnviT ==t
Marne3 V� si AvC. TEWA�
Company._ —olo rater ,019 Q_...._59 SOUTH KIMBALL..ST.
7. location where contents were disposed, BRADFORE), MA 01 835
SigRakure o auir Cate
$igttafure oft er'etVing racility' -- crate
15form4.doc•07106 System Pumping Reco+d page t of t
r