HomeMy WebLinkAboutSeptic Pumping Slip - 546 Sharpners Pond Rd - 01.03.2025 - Septic Pumping Slip - 546 SHARPNERS POND ROAD 1/3/2025 Commonwealth of Massachusetts Town of Nofth Andover
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of HealH11 but the
information must be st,ibstantially the same as That provided here. Refore using this r , check with your
local Board of Health to deterrnlne the form they use. The System Purnping Record must be submitted to
the local Board of Health or other approving authority within 14 days from -.he purnping (.date in
accordance with 310 (,MR 15.351 _.__.._ -._ _._.._.
HOUSE: front ba < side rear left rigl
A. Faculty Information BUILDING: front bac ide rear left r
Ymr>ortant;When
DECK: under
fllling out forms 1. System t oCattC,
or)the computer, L f
use only the tabi�r
key to move your Address J
cursor-do not t/ M p
use the return f
key C lyrrown Siaie Zip Code
U 2. Wyn
r<t
nova
Address (il diffr;ronl from loc<rllon)
M A,
c
CflyfTowo slate - Z Code
Telephone Number
B, Pumping Record
3 1. Date of fDurnping - _._._._._.___� , Quantity Pumped
ale . Gallons
Y
3. Component (_J Cesspool(s) Septic `Bank ❑ Tight Tank Grease Trap
r
Other (describe):
l
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No
5. Observed condition of componenl pumped
}
6. System Purnped By
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License Number
32keson Enterprises, Inc.
l Company
r
7 Location where, contents were disposed:
I' GI_SD
r
}
Signature o( liaul r Oate __._.__
----------
signature of Receiving Facility (or ,.tU.si_h facility (r,cclpl) Date
r
k
l5lo(m41.doc- 11112 System Pumping Record Page 1 of 1