HomeMy WebLinkAboutSeptic Pumping Slip - 700 CHICKERING ROAD 5/2/2016 Commonwealth Of Massachusetts
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Systern Purnping Record NORTH ANDOVEWwru
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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:
When ruing out 1. System Location:
forms on the /-
computer,use
onl�r the tab key Address
to move your
cursor-dc not
use the return City[Town Stale Zip Code
key.
_ 2. System Owner:
Name
❑"'° -
Address(if different from location)
-- to
City/Town 533 Zip Code
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Record
Telep e Number
B. Pumping --- - - —
1. Date of Pumping 2. Quantity Pumped: Ga ions
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tan< ,Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By, /
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Nauler Da e
Signature of Receiving Facility Date
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