HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 585 SHARPNERS POND ROAD 3/16/2026 Commonwealth �� K�Massachusetts
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System Pumping�� Record
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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 be substantially the eomm as that provided here. Before using this form, check with your
local Board of Health 1odetermine the form they use. The System Pumping Record must be submitted to
the |ouo| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCyWR15.35l.
A. Facility Information
Important:When
filling out forms 1. System Location:
cm the computer,
use only the tab 585Sha Pond R d
key tn move your xdumso
cursor do not
North Andover MA 01845-3336
use the mmm
key. City/Town ,^.^, Zip Code
2. System Owner:
~----^ JoshuaLedemn
Name
Address(if different from location)
Cnity/Town State Zip Code
617-481-5728978-652-6754
Telephone Number
B. Pumping Record
1. Date wfPumping 3/16/2020 1500
Dme 2. Quantity Pumped:
Gallons
3. Type nfsystem: CeeepomKa\ Z Septic Tank Tight Tank Fl Grease Trap
n Other(describe):
4. Effluent Tee Filter present? Yes Z No |f yes, was itcleaned? Yes Z No
5. Condition of System:
Good, system operating properly
8. System Pumped By:
Jason Elliott S71437orV85257
|veeter and Elliott Services LLC-DBAJason
ElliottPumping
7. Location where contents were disposed:
GLSD
3/16/2026
S re of Hauler Date
Signature of Receiving Facility Date
t5fonn4dmo^0308 System Pumping Record^Page 1uf6