HomeMy WebLinkAboutSeptic Pumping Slip - 361 CHICKERING ROAD 2 6/7/2018 of Massachusetts
of No. Andover, MA
Pumping Record
II �
DEP lir r)rovided this form for use by local Boards of Health. Other forms may be used, but the
ini`or r must be substantially the same as that provided here. Before using this form, check with your
of 1-;ortTl to r1:tr3rmirre the form they use. The System Pumping Record must be submitted to
the for ai Board of Health or other approving authority within 14 days from the pumping date in
accorcrancm with 310 CMR 15.351..
__. --_..- —--
Impor•ra.unti:When
filling oo'' �.AnIs 1. l)C7c1'llJCt:
on the curnputer,
use only tt,e tab _ CVJ/,CEr //�7 t k1d
a�
key to rncnv;your d,l — _.. .
cursor-do not
Ma
use the return _ _
key.
C State Zip Code
Owner:
rea_ 11
�' ....
of different f'orn location)
C'P,y"Tor vn State Zip Code
... -.. .._..._.. .....
Telephone Number
@:zumpon0 Date....:... Quantity Pumped: Gallons
Cesspools) 0ptic Tank ❑ Tight Tank ❑ Grease Trap
4. �o tlr;tr,, Tee Filter present? 1-1Yes r /No If yes, was it cleaned? ❑ Yes ❑ No
6. r�ondi ion o compo int pu ped:
E7 �, ,..,_ Llrnped y:
jJ
Ids rrr Vehicle License Number
I
te,w sr 's Septic 58 So. Kimball St., Bradford,MA,
Carrrlaa-.dory i
7, Ux atir:,n where contents were disposed:
20 Sol l"Vlill St., acT rd, MA
Sidi a ure,of Haule Date
—.. — ._.... _-----— - ..__...._— ...... - ._......—
S nao rc�of Receiving Facility(or attach facility receipt) Date
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