HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 672 SHARPNERS POND ROAD 5/26/2022 Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER
System Pumping Record
Form 4
M
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 pbQ submitted to
the local Board of Health or other approving authority within 14 days from the pumASin
accordance with 310 CMR 15.351.
A. Facility Information MA`(
Important:When NORMH PN ENA
filling out forms 1. System Location: SOWN OFN I)SPw M
on the computer, HEP,JT
use only the tab 672 SHARPNERS POND
key to move your Address
cursor-do not NORTH ANDOVER _ MA 01845
use the return Cit /Town
key. y State Zip Code
2. System Owner:
KLAUS SCHLEICHER
-- - --
Name
rsnm
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 5/13/22 2. Quantity Pumped: 1500
Gallons
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
SS SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD _
5/13/22
S ature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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