HomeMy WebLinkAboutSeptic Pumping Slip - 660 SHARPNERS POND ROAD 9/24/2016 Z\ Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this fdrrn 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 Hf-alth to determine the form they rase_The Systern 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;
Whin filling out 1, Sys em Location:
forms on the l ,
computer,use
only the tab key ddress
to move your
Cursor-do riot .......... ukate _ . Zip Code,.
use 0e return s y awn
kBy. 2. $ystern Owner:
VQ
Name
Address{if different from location?
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CityrTawrr ate zip Codde� Y
Tetepttone Number
B. Pumping Record
, Dace of Pumping �. Quantity Pumped:Pumped:`t Gairons
pate
3, Type of system: Cl Cesspool(s) Septic-rank ❑ Tight Tank ❑ Greere Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
qoo
6. System Pumped By:
Name Vehicle L11, se tvumger
Company
7. Location where contents were disposed,
Signature of F•la�ler ..Rate
4A.. Poster ...
Signature pf ROCeiving Facility - - ---------- Date (978) 374-2382
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