HomeMy WebLinkAboutSeptic Pumping Slip - 267 CHICKERING ROAD 5/16/2016 Commonwealth of Massachusetts
_ City/Town of
System Pumping scar d 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
Important:
When filling out 1. System Locatio'n�:`
forms the �✓ y'
computer,r,use
only the tab key Address
to move your — rI�'
cursor-do not
use the return City own S ate Zip Code
key.
2. System O ner:
h'
Name /
Address(it different from location)
City/Town State 'i�l Zip Code
y
____C1�_ -
Telephone Number
B. Pumping Record --- ---- —
1. Date of Pumping -- f— - — -- 2. Quantity Pumped.
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E&'No If yes, was it cleaned? ❑ Yes
5. Condition of System:
f"
6. System Pumped
Name Vehicle License Number
STF
Company.-.... .- - 7 '� _..__ ._....._ . - +✓Wr1 � 61 E . I
SOUTH KIMBALL T.
7. Location where contents were disposed: FAF , MA 01835
Signature of Hauler Date
Signature of Receiving Facility Date
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