HomeMy WebLinkAbout- Septic Pumping Slip - 267 CHICKERING ROAD 10/3/2018 F D
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS 0(""',f
System Pumping Record
rs [-1EA[ DUM'0 rVEN'1'
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 filling out 1. System Location:
on
forms on the
/I
computer,use
y ly the tab key ress
to move your North Andover Y_MA 01845
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
b A�
Name
Address(if different from location)
CitylTown State .Zip,Code
Telephone Numb6
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: F Cesspool(s) ❑ Septic Tank R Tight Tank
ltq Other(describe):
4. Effluent Tee Filter present? [_1 Yes No If yes,was it cleaned? ❑ Yes El No
5. Condition of Sys 'M:
6. System Pyi ed By: tense urn:b:��r:_
—Ve—h—icle WL
Wind River Environmental L)
Company..
aAn
7. Location where contents were di ;N'
Signature o au er Date—
http://www.mass.gov/dep/wate /approvals/t5forms.htm#inspect
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