HomeMy WebLinkAboutSeptic Pumping Slip - 336 SHARPNERS POND ROAD 9/30/2016 Commonwealth of Massachusetts
- City/Town of
System Pumping Record NORTH ANDOVER
Form 4
pE='fi has provided this form for use by fatal Boards of Health, Other farms may ba usad, Batt the
information must be substantially the same as that provided here- Before using this form, check with your
10021 Board of Health to determine the form they use. The System lumping Record must be suiomttted to
the focal Board of Health or other approving authority within 14 days from the pumping data in
accordance With 310 CMR 15.351.
A. Facility Information .
fmpaFtant:
when filling out 1. System Location:
(owns the — ► l� C...
computer.use
only the tab key Address
torooveyour
use the retum CityrrowR State Zip cose
key. 2, System Owner:
Name
— — -
Ad--dr�55(If pfffereni from 1oC�tipn)
City/Tgwn State Zi code
Talephone Number
B. Pumping Record
1, 0ate of Pumping �� ° � 2. Quantity Pumped' „
Date
3. Type of system: Cesspool(s) Septic Tank ❑ Tight Tank ] Greasy Trap
Q Other(describe):
4, Effluent Tee Filter present's Yes ❑ No If yes, was it cleaned? Yes � No
5. Condition of System:
6. System Puumped By:
Name Vehicle-Lfcense Number
W-
C0 pasty
T. Location where contents were disposed:
Haverhill WWTP
Signature of hauler
SigrtatTre of Receiving facility -�--�--��------`-�-- --� l]
( 73) 374-2382
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