HomeMy WebLinkAboutSeptic Pumping Slip - 614 SHARPNERS POND ROAD 1/11/2018 �- Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
-gym
System Pumping Y p g Record
Form 4
r-
DEP has provided this form for use by local Boards of Health. The System Pumping Record must 1
be submitted to the local Board of Health or other approving authority. J
A. Facility Information
Important:
When filling out 1. System Location: i
forms on the
computer,use 61
only the tab key Address – — - —_
to move your p r
cursor-do not
use the return Ci frown
key. State
iiCode
2. System Owner: �J°I
Name
Address(if different from location)
CityfTown —.___._ _—
Stake Zip Code
`telephone Number
B. Pumping Record
1. Date of Pumping — — _ 2
Dale _ Quantity Pumped: talions
3. Type of system: ❑ Cesspool(s) E eptic Tank ❑ Tight Tank
❑. Other(describe):
4. Effluent Tee Filter present? Yes [] No If yes,was it cleaned? Yes El
No
5. Condition of System: 0/-
6. System Pumped By:
Name Vehicle License Number
Company _-�
7. Location where contents were disposed:
4 111-,F l
Si nature oft
g ia�er�---- Date
http://www.mass.gov/dep/water/approval forms.htm#inspect
t5form4.doc•O6/03
System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER2 MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Wealth. The System Pumping Record must
be submitted to the local Board of Wealth or other approving authority.
A. Facility Information 's
Important:
When filling out 1. System Location: �(
-...-�2--..-.- - -- 9
forms on the
computer,use _ =..GJ! `�~,
only the tab key Address ��
to move your pmt
cursor-do not �.-.._,_..—. _.
Ci /Town _`. ..._._. ._
use the return �' �-- {"
key. �`���
State Zip Code
2. System owner:
Name
City/Town —_.--.---__,__ ___
State Zip Code
Telephone Number
B. Pumping Record
1. .Date of Pumping
Bate - 2. Quantity Pumped: -----__._
Gallons
3. Type of system: Cesspool(s) Septic Tank [] Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? E Yes ❑ No If yes,was it cleaned? Yes ❑ No�
5. Condition 11of System:
� b cS — —
6. System Pumped By:
Name _ Vehicle License Number --- — ._.— .
Company -
7. Location where contents were disposed:
Signa ure of hiaAer - -_ -----.__.
Date
http://www.mass.gov/dep/water/approva s/t5forms.htm#inspect
1
t5form4.doc•08/03
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Wealth. The System Pumping Record trust
be submitted to the local Board of Health or other approving authority.
- w
A. Facility Information
Important:
When filling out I. System Location:
farms the 1
computer,use _ � �L f11"E"i S (Csw lY ,t t
only the tab key Addross _ — --- --- — °—x=- _
to move your
cursor-do not
use the return City/Town State �� —
Zip Cade
key.
2. System Owner:
Q / ) I l-fLw-J e-,
Address(if different from location) —
i
-S—tat
S_—tate Zip Code `
Telephone Number
B. Pumping Record
`I. Date of Pumping �`' 7 S'- `�°f
p g Date 2. Quantity Pumped: Galtams
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): -- _
4. Effluent Tee Filter present? [--il-Yes ❑ No If yes,was it cleaned?
13" es ❑ No Y
5. Condition of System:(
C CL
6. System Pumped By:
621
Narpe Vehicle License Number
Company _
7. Location where contents were disposed:
'Lu
Signa aof Hauver
htp://www.mass.gov/dep/water/approvals� Date
. # p
s�
i
t5form4.doc•06/03
System Pumping Record•Page 1 of 1