HomeMy WebLinkAboutSeptic Pumping Slip - 700 CHICKERING ROAD 10/16/2017 'SRECEIVED
Commonwealth of Massachusetts
Cit /Town of
System Pumping Record NORTH ANDOVER jo%t�or�tAOIR
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 rifling out 1. System Location:
forms on the
computer,use
only the tab key Add4Rt
to move your
cursor-do not
use the return City/Town State Zip Cod-e'
key-
2, System Owner:
Name
Address(it different from location)
Cil /Town State ip Cod
Telephone Number
B. Pumping Record
1, Date of Pumping 0 2. Quantity Pumped:
Date Gallons
I Type of system: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of 5y tem:
6. Systerrj-E:'_u>�riped By:
le_ d-RivVehicle License Number
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—DRADFORD, MA o1835
l5form4.doc-03/06
System Pumping Record-Page I of I