HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 374 SHARPNERS POND ROAD 11/28/2022 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
System Pumping Record /'0Wj OV28 2022
il
10 Form 4 yFq�T �Vo
M
EPq �Dp�
DEP has provided this form for use by local Boards of Health. Other forms may be us
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 374 SHARPNERS POND RD
key to move your Address
cursor-do nct NORTH ANDOVER MA 01845
use the return key. City/Town State Zip Code
�1 2. System Owner:
V� JAMES FARO
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 1500
Date 11/21/22 Quantity Pumped: 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 CONDITION
6. System Pumped By:
JAY CURRIER_ _ H79406 _
Name Vehicle License Number
J'S SEPTIC & DRAIN
Company
7. Location wh contents were disposed:
GLSD 11
__ -- - - -- -
_ 11/21/22
Sigtfature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1