HomeMy WebLinkAboutSeptic Pumping Slip - 361 CHICKERING ROAD 12/8/2016 Commonwealth of' Massachusetts
City/Town of No Andover
System Pumping Record
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, RECEIVED
A. Facility Information ULL' U 8 ?016
Important:When
filling out forms 1. System Location- TOWN U-[,dOK I H M.)(,NER
on the computer,
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se only the tab
key to move your Ad e
cursor-do not
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key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record da-)
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s)
Septic Tank ❑ Tight Tank [:1 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2---No If yes, was it cleaned? [:1 Yes ❑ No
5. Observed condifil o al of com nent pumped:
------------
e 'e
6. ped
erne-s�te Vehicle License Number
Stewarts Se mball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mil t brA for jd'rna
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Signatu e of Hauler- Date
Signature of Receiving Facility(or attach facility receipt) -Date -
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