HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 542 SHARPNERS POND ROAD 7/15/2020 Commonwealth of Massachusetts RECEIVE®
City/Town of _ A\y)60VeV JUL 15 ZOZU
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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, �" L � 1_ �.,I r, 100-) 1 �ni, RA
use only the tab T 1'�(.t.. S I 1`CJl
key to move your Address �V� ,I
cursor-do not / . A n coo y ty. MA C) i IR 4S
use the return Cityffown State Zip Code
key.
2. System Owner:
ChO,r 1 Si yy)ona
Name
nam
Address(if different from location)
City/Town State ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date-7
at? G 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) N 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:
GC)/)CA
6. System Pumped By:
,Tirv, Do c I f 5733 As
Name Vehicle License Number
Service Pumping&llraii,Cu.,i„,
Company North Reuling,MAo1864
7. Location where contents were disposed:
L S b
c
Sign re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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