HomeMy WebLinkAbout- Septic Pumping Slip - 700 CHICKERING ROAD 1/8/2019 Commonwealth of Massachusetts j
a R City/Town of NORTH AND+O►VER MASSACHUSETTS
_ . System Pumping Record
P I
.'" Form 4
I
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:
forms on the
computer,use (.k. G ke V
only the tab key Addressto move your North Andover
cursor-do not City/Town _. MA 01845
�
use the return State � Zip Co..._.____de
key.
2. System Owner:
Vk]
Name __._..
Address(if different from
-it
Cityfi"own
Stato Zip Code
Telephone Number ——
B. Pumping Record
1. Date of Pumping aaf-a� 4f 2. Quantity Pumped: -
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
0 Other(describe): �rho ,e
4. Effluent Tee Filter present? ❑ Yes El./No If yes,was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number _
_Wind River Environmental
Company — ..... —_
��TEbVN,Fi`1`S SEPTIC SERVICE
7. Location where contents were disposed; 58 SOUTH KIMBALL ST
MA 41835
Signature of Hauler � Date
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
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