HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 336 SHARPNERS POND ROAD 6/7/2021 Commonwealth of Massachusetts
- City/Town of uo ve
y
System Pumping Record
v, 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 Heap �LMtk%Dhe form
they use.The System Pumping Record must be submitted to the local Board of Health or other approvefi' A erny within 14
days from the pumping date in accordance with 310 CM 15.351 _ tl IAhT201
A.^Facility Information
1. System Location: TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
336 Snaroners Pond Road
Address
North Andover 01845
CitylTown State _ _ Zp Code
2. System Owner:
Ellen & Brian Fiatzgerald
Name _
336 Sharpners Pond Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9782586272 xhome_.____
Telephone Number
B. Pumping Record
1. Date of Pumping Date 05/10I2021-- - 2. Quantity Pumped. Gallons
0000 -_
llallons
3. Component: ❑ Cesspool(s) a Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes,was it cleaned? 0 Yes No
5. Observed condition of component pumped:
see.. �tox»�alr�sa�c r =eve p so?�•ds--".1oci�za: ..hatosa--.----.
-s-lndagep."Rotiz _ F--r iji presen—t--and licit, been
leaned As Cover s sectisea.Recatruiii?nde cost a itive,CCLS a it�ve
6. System Pumped By:
Michael Graham. _
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Streets S e IF110, Hudson, MA 01749
Company
7. Location where contents were disposed:
rater Lawrence Sanitary District t 240 Charles Street , North Andover, MA
05/10/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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