HomeMy WebLinkAboutSeptic Pumping Slip - 267 CHICKERING ROAD 8/12/2016 ZN Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
OAP has provided this farm for use by local Boards of Health. Other forms may be used, but the
information must be substantially the saute as that provided here_ Be ere using this form, check with your
local Board of Health to determine the form they use_The System Primping Rgcdtd must be submmtted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 10.351.
A. Facility Information
Importartt:
When rifling out I, System L Qo2tion:
Forms on the r'� w
computer,use .,/ .-6- 4 t..,.
orvy the tats key Address
14 move your �7A1 ( 1I
Cursor �4n4i T — -- •—�..-' .... .. ... }1. ._ _ ...`
use the return Csryfr'own State Zip Code
Rey. 2. System weer:
Name
Address
—(—d d�ffg. _.�.rgnt tram foca(=on_}...._—.._...— _...— .. __.. ... . ... ... �.,... ,..W ._-.,
Cityr7awn State /+ Zip code _..
.~
Blaphone r....ti .. y ._
B. Pumping Record
1. Date of Pumping - - 2. Quantity Pumped:
Pate Gallong
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank � ease"trap
❑ Other(describe):
4. EfflUerit T 2 Fitk r present? ❑ Yes hto If yes, was it cteened? ❑ Yes P-K-O
5. Condition of System; j
8. System Pumped y- � Wind� Wcs I]Y]PUIx1I]C,C7 kt ,]��
NBrr;e r fA oM I License Number
- -- - — - ` —�- -,- j
c1-1 pang STEWARTS SEPTIC SERVICE
7, location where contents were disposed: 58 SOUTH KIMBALL ST.
r, w . .._. _...�__.._... ...__... . . ._.�._. B.RADFDRQ,-MA.Cl1.835....—_...,_. .... .
975-372-7471
Signature of Hauler -- Date
Signature of Receiving Facility Date
IS orrnd.doc•03�t}6
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