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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 540 SHARPNERS POND ROAD 6/11/2021 Commonwealth of Massachusetts RecoVED City/Town of NORTH ANDOVER SUN 7 7 �0?� System Pumping Record T HF-4LTOWAf N©�, a Y p� 9 HEgCTy o>;p ovvgR HAN w„ Form 4 ARTMFNT 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, use only the tab 540 SHARPENRES POND RD key to move your Address cursor-do not NORTH ANDOVER MA 01845 use the return key. City/Town State Zip Code 2. System Owner: JACKIE CRONIN Name --- --- renm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 6/7/21 — 2. Quantity Pumped: 15I00 Datens 3. Component: ❑ Cesspool(s) ® 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: GOOD 6. System Pumped By: JAY CURRIER_ _ H79406 Name Vehicle License Number J'S SEPTIC & DRAIN Company 7. Location where contents were disposed: G 6/7/21 ignature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1