HomeMy WebLinkAboutSeptic Pumping Slip - 267 CHICKERING ROAD 4/3/2018 Commonwealth of Massachusetts
a
City/Town of VOR H�R MASSACHUST CEIVED
s System Pumping Record
Forms 4F)[) n 3 2018
DEF' has provided this form for use b local Boards of Health. The System
p y F-i )LgWj DOVER
be submitted to the local Board of Health or other approving authority. " tai
A. Facility Information
Important:
When filling out 1. System Location:
forms on the ( ^� ("
computer,use �+ f _`— ( (\d1
only the tab key Address
to move your North Andover
cursor-do not -- _—_ MA 01845
use the return City/Town �__...�,_ _� State Zip Code
key,
2. System Owner:
VQ b
Address(ifdifferent from location)
Clky/Town -- Stat
/Zip Code
C'/ c
Telephone Number
B. Pumping Record
1. Date of Pumping 0 ti �! 2. Quantity Pumped: J
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
:, Other(describe): —C' K --i r e 5 - \z"-
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Wind River Environmental
Company �_�
7. Location where contents were disposed: STEWART S SEPTIC SERVICE
------- ..St�UTt-I KIMBALL ST,
t
Signature of Hauler
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
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