HomeMy WebLinkAboutSeptic Pumping Slip - 374 SHARPNERS POND ROAD 11/23/2016 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
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 forms 1. System Location:
on the computer,
use only the tab 374 SHARPNERS POND RD ...........
key to move your Address ❑
cursor-do not NORTH ANDOVER MA
use the return
City/Town State I Zip Code
key.
2. System Owner: TOWN op AM)OVEp
HEA 1'�
JAMES FARO ..............I
Name
Address(if different from location)
dit—yfTow"n—""" -- ,-....... —State- -Z—ipCo"d'e"—,
Telephone Number
B. Pumping Record
11/23/16 1500
1. Date of Pumping Date---- 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank F-1 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? F-1 Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER 11 H79 406
Name Vehicle License Number
XSEPTIC & DRAIN
Company--.—
7. Location where contents were disposed:
GLSD
4%7
11/23/16
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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