HomeMy WebLinkAboutSeptic Pumping Slip - 361 CHICKERING ROAD 5/31/2017 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover
System Pumping Record TOVVN OF NOFM4 RMOVER
Form 4
hEALT�t DEPARWINT
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 purn,44,100 to in
accordance with 310 CMR 15.351. ul 14"n151,
V4' ''
---------- 1-1110 o I
A. Facility Information
%4)
Important:When
filling out forms 1. System Locatlqn'.
101
on the computer,
use only the tab ---------------
key to move your Address
cursor-do not
North Andover
usethe return .. .... ---------------------------------------- —------------ .....
key. City/Town State Zip Code
2. System Owner:
............
Name
retrxn
Address(if different fromlocation)
.. ..... - ------------------- .........................
CityfTown State Zip Code
Telephone Number____,_,.........
B. Pumping Record
1. Date of Pumping Date 2, Quantity Pumped: 606
Mons
3. Component: ❑ Cesspool(s) Ej~'teptic Tank El Tight Tank n Grease Trap
❑ Other(describe): ---------------
4. Effluent Tee Filter present? El Yes K3Ivo If yes, was it cleaned? E] Yes F-1 No
5. Observed condition of component pumped:
............ ............
6. System Pumped;
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
20 so mill st bradford ma
-------------
Signature of Hauler Date
Signature of Receiv".ci�,�., f7fMt7tach facility receipt) Date
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