HomeMy WebLinkAboutMiscellaneous - 15 Sharpners Pond Road c
Commonwealth of Massachusetts
City/Town of NO. ANDOVER
System Pumping Record
Form 4
M yr y
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. RECEIVED
A. Facility Information
Important: SEP 3 0 2008
When filling out 1. System Location:
forms on the TOWN OF NORTH ANDOVER
computer,use 15 SHARPNERS POND RD. HEALTH DEPARTME
only the tab key Address
NT
to move your NO.ANDOVER MA 01845
cursor-do not C !Town
use the return State Zip Code
key. 2 System Owner
QRESIDENT
Name
7e0°" Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pie/08 2. Quantity Pumped: 2000Gallons
3. Type of system: ❑ Cesspool(s) 9/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes UKNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Benjamin Shute H79 406
Name Vehicle License Number
J's Septic& Drain
Company
7. Location where contents were disposed:
GLSD
9/24/08
atrofHauler Date
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