HomeMy WebLinkAboutSeptic Pumping Slip - 700 CHICKERING ROAD 1/19/2016 L
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
When filling out 1 System Location.'
forms on the
computer,use
onty the tab key AM At,e 5 jJ
to move your
r JP V-ea
-C!
-do not Zip Code
cursor 4 State
use the return
key.
2. System Owr)er
V�
Name
Address(if different from location)
di—yiTow-n- State Zip-,—Cod-e--
83.
_j
Telephone Number
B. Pumping Record
1. Date of Pumping iy�(.e 2, Quantity Pumped:
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank 'E1,6fease Trap
❑ Other(describe):
4. Effluent Tee Filter present? No
E111"Yes r-1 No if yes, was it cleaned?
5. Condition of Syst
6. System Pumped By:
Wind River Environmeutal
Name I63 Wesitern Ave. Number
-Glouonter,-MA.01930-
-6ompany
7. Location where contents were disposed:
---STEWARTS SEPTIC-SERVICE--
56 SOUTH KIMBALL ST
signat U of Date BRADFORD, MA 01835
978-372-7. 4-T
Signature of Receiving Pacili Date
t5fo(m4,doc-03106 System Pumping Record-Page I of I