HomeMy WebLinkAbout- Septic Pumping Slip - 374 SHARPNERS POND ROAD 12/20/2018 rii,,, II
Commonwealth of Massachusetts ECE
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City/Town of NORTH AN ROVER
System Pumping Record [\rqt��OVER
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 CIVIR 15.351.
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A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab .374 S.HARP-N ERS PO.N-D-.RD,--
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return
key. City/Town State Zip Code
Q2. System Owner:
JAMES FARO
Name
rerum
...........----------------------------
Address(if different from location)
City n-------- State Zip Code
Telephone—Number
B. Pumping Record
1. Date of Pumping 11/30/18 2. Quantity Pumped: 1500
Date Gallons
3, Component: ❑ Cesspool(s) ❑ Septic Tank F-1 Tight Tank ❑ Grease Trap
F-1 Other(describe): ...............I I'll-,...............-.................
4. Effluent Tee Filter present? F-1 Yes El No If yes, was it cleaned? F 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
.................
11/30/18
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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