HomeMy WebLinkAboutSeptic Pumping Slip - 374 SHARPNERS POND ROAD 12/4/2017 �.._. Commonwealth of Massachusetts REC
x City/Town of NORTH ANDOVER
System ping Record7`
Form 4 wNOF NORTH ANDOVER
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 _._._...__ ._.._._.....w__ .._._._...__.. .......
cursor-do not NORTH ANDOVERMA 01845
use the return —._ __ _�__ _____ ____._._._,._........_._.,_..__. -
key. City[Town State Zip Code
2, System Owner: 1
JAMES FARO i
Name
�ercrn
Address(if different from location)
City/Town State Zip Code
Te _...._e Num...... .._.bera__....._B. .... ..._ --.
Pumping Record
lephon
11/28/17 1500
ate
1. Date of Pumping _ ---_-- 2. Quantity Pumped: L_all____ans___ ._._....w ._..____..__ _.......
D
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ___._._._.. ........ _...._._
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD
6. System Pumped By:
JAY CURRIER H79406
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
�f
..11/28/17
Sign6ture of Hauler lake
Signature of Receiving Facility(or attach facility receipt) Date
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