HomeMy WebLinkAboutSeptic Pumping Slip - 700 CHICKERING ROAD 5/11/2017 :RECEIVED
Rte, Commonwealth of Massachusetts
j
City/Town of NORTH ANDOVER, MASSACHUSETtS 0�NoRIH ANDOVERI Uyv' L NT
Tji DEPARWE
System Pumping Record I H EA
Form 4
DEP has provided this form for use by local Boards of Health.. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important
when Ming out 9. SNIC%tem Location!
forms on the
computer,use
11 &
on'ly the tab key Address MA 0.1845
to move your North Andover
cursor-do not Cityrrown state zip Code
use the return
key.
2. system Owner:
C)V e
b y- Ll I
1-7 Q b C 11 C- K
A ress(ifdiff entfrorn ocatfon)
am"
Mz!
Cityrrown state Code
Wiephpne NUmbar
B. Pumping Record
2, Quantity Pumped: Gallons
1. Date of Pumping Date
3. Type of system: El Cesspool(s) El Septic Tank El Tight Tank
;
0?-8ther(describe):
4. Effluent Tee Filter present? 0 Yes ErN-'o it yes,was it cleaned? F-1; Yes
5. Condition of System:
6. System Pumped By.,
:5MICE—
SMA 1W iw�"F� ,
Wind River Environmental 68 SOUTH KIMBALL ST.
Company BRADFORD, MA 01835
7, Location where contents were disposed*
978-372-74'71
4--Rinature of Hauler Date
http!//www,mass.gov/dep/Water/approvals/t5forms.htm#inspect
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