HomeMy WebLinkAbout- Septic Pumping Slip - 267 CHICKERING ROAD 12/10/2018 Commonwealth of Massachusetts
City/Town of NORTH TT
System Pumping Record
y� Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must J
be submitted to the local Board of Health or other approving authority.
A. mmFacility Information _--- - }
Important:
When filling out 1. System Location:
forms on the
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anlnpfieetab ke Address
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to move your North Andover MA 01845
cursor-do not City/Town _.. _.-,_
use the return State Zip Code
key. 2. System Owner:
Name __�._....
Address(if different from location)
City/Town
State Zip Code
r
Telephone Number
B. Pumping Record
1. Date of Pumping -� -- 2Date , Quantity Pumped: — c'c� — —
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes MNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name License Number
Wind River Environmental
Company
7. Location where contents were disposed:
—
ADF0RD, A Q11
Signature of Hauler -- 7 Tm7471
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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