HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 486 SHARPNERS POND ROAD 8/19/2025 Commonwealth nfMassachusetts
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Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must bo substantially the same aa 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 318CK8R15.351.
A, Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 486Shu Pond Ro d
-------------
key to move your *udmon
cursor-do not
North Andover [WA 01845
use the return
key. ~'^'''—'' State —, ---
2. System Owner:
^---~ Jagtap
t
mama
-Address(if differentfrom location) -----
ity[Town State Zip Code
978-223-5200
elephone Number
B. Pumping Record
8/19/2025 1500
1. Date of Pumping 2� Quantity Pumped:
Gallons
3. Type ofsystem: [l Cesspool(s) E Septic Tank El Tight Tank Fl Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? Yes E No
5. Condition of System:
Good, t hproperly
S. System Pumped By:
Jason Elliott S7i43Yn/V8G2�7
ame Vehicle License Number
|veater and Elliott Services LUC-OBAJason
Elliott Pum ping
7. Location where contents were disposed:
GLSD
8/19/2025
r;of Hauler Date
tsmrm*xuo^oa/os System Pumping Record~Page 1ms