HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 374 SHARPNERS POND ROAD 11/30/2021 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record
y` Form 4
M
DEP has provided this form for use by local Boards of H',ealth. Other forms may be used, but the
information must be substantially the same as that proviided here. Before using this form, check with your
local Board of Health to determine the form they use. Tt-ie System Pumping Record must be submitted to
the local Board of Health or other approving authority wiithin 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 374 SHARPNERS POND RD
key to move your Address
cursor-do not NORTH ANDOVER _ MA _ 01845
use the return Cityrrown State Zip Code
key.
�Il 2. System Owner:
V� JAMES FARO
Name
reom
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 11/22/21 2. Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) ® Septic 117ank ❑ 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 ere contents were disposed:
GLS
da.s� 11/22/21
gnature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1