HomeMy WebLinkAboutSeptic Pumping Slip - 12-13-2024 - Septic Pumping Slip - 374 SHARPNERS POND ROAD 12/13/2024 Commonwealth of Massachusetts
w City/Town of NORTH ANDOVER
System Pumping Record
- Form 4
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.
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A. Facility Information 9,�ni
Important:When y
filling out forms 1. System Location:
on the computer,
use only the tab 374 SHARPNERS POND RDA
......_.....
key to move your Address
cursor-do not NORTH ANDOVER MA
use the return - _.___. .
_
key.
City/Town _.. State
2. System Owner:
r�
JIM FARO
Name
refrxn
Address(if different from location)
City/Town State Zip Code
Telephone Number
__._.........__.._....._._.__.._..._._..- --.....-.._........__.....--...............__...........-._....
B. Pumping Record
500
1. Date of Pumping — _12/13/24 _.._ 2. Quantity Pumped: -1--
Date 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 where contents were disposed:
GLSD
i tti r f Hauler 12/13/24
S)g atu e o Date
Signature of Receiving Facility(or attach facility receipt) Date
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