HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 JERAD PLACE 12/1/2020 Commonwealth of Massachusetts RECEIVE)
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System Pumping Record oR1HPNp0
' Form 4 ��WN of ND�PPR�MENT
DEP has provided this form for use by local Boards of Health.Other forms may be used,but Mttformation 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
1. System Location:
25 Jerad Place
Addnm
North Andover MA 01845
City/Town toe "code_ -
2. System Owner:
Kathy & David Bardwell
Name _.
25 Jerad Place
Address(if different from location)
North Andover - _ Mrs - 01845
City/Town . State _ Zip Code
9786859004 xhome
Telephone Number
B. Pumping Record
1. Date of Pumping 11/19/2020 2000.0000
p g Date--- - 2. Quantity Pumped: -- ------
Gallons
3. Component: Cesspool(s) FV1 Septic Tank Tight Tank n Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes FY No If yes,was it cleaned? Yes ❑No
5. Observed condition of component pumped:
System—.Opera 7.t1Q.-.Fin=_ -Normal ma-taz—J*Vja1—_ua�.� T_ top_-Soli"-- '
Sludge-�3IIth-baffIvs-are =-rtzc` 4aiZt-11me--dear--No—ttlter--±5--present ,
current tan' ik is not e�igned to a use wit a fi t over s securea. Pumpo-a—
2000 gallons. Recommended Boost additivill additive.
6. System Pumped By.
' Marcus Lark
Name Vehide Lioeose Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
11/19/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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