HomeMy WebLinkAboutSeptic Pumping Slip - 267 CHICKERING ROAD 5/2/2016 Commonwealth of Massachusetts
:. City/Town of
System urnpi Record NORTH AN DOVE
Form 4 fief
DEP has provided this form for use by local Boards of Health. Other forms m4r�6�[6�s" , ,w
information must be substantially the same as that provided here- Before using this form, eh�&4ilrh 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:
Mien filling out 1. System Lac tion:
forms on the ��/}�1
computer,
tab key Adtlre�G riLd`. e'__N l'Y'r
/ s
io move your CityTownf ` ! State 1 CY ,
cursor-do not 1� �
use the return to Zip Code
key.
2. System Owner:
Name
�'-- Address(if different from laca(ion)
City/Town State Zip Code "
Telephone Number
B. Pumping Record ---
1. Date of Pumping -- — — — 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspooi(s) ❑ Septic Tank ❑ Tight Tank j- Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ( °No If yes, was it cleaned? ❑ Yes D–No
5. Condition of System:
6. Sy �em Pumped (�
Name l ,,-}� ., Vehicle License Number
Company
7. location where contents were disposed.
SOUTH KIMBALL Td
Signature of Ha ' Date
Si nature of Recw°i� �acili - Date __._..._
978-372-7471
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