HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 162 HAY MEADOW ROAD 12/14/2020 R ftelveD
Commonwealth of Massachusetts DEC 14 2020
f City/Town of North Andover 110w/V 0"IV A
RINDNrER
System Pumping Record H�LTH pEp MF
y, Form 4
ealth.Other forms may be used,but the information must be
DEP has provided this farm for use by local Boards of H
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:
162 Hay Meadow Road --
Address KA 01845
North Andover to
ity/Town
State Zip Code
C
2. System Owner:
Sarah Tiber _— --
Name
162 Hay Meadow Road
Address(if different from location) MA
018 4 5
North Andover
State Zip Code
City/Town
6175048800
Telephone Number
B. Pumping Record
11/09/2020 2000.0000
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) �Septic Tank Tight Tank Grease Trap
Other(describe): _ ---
4. Effluent Tee Filter present? 0 Yes FRI No If yes, was it cleaned? Elyes No
5. Observed condition of component pumped:
System operating Fine Normal water la'joj 14 xiex_at_e�
current tank is not designe to be used with a filter. Covers) secured. Recmd. Not
flushing wipes. Recmd. Install riser. 15 inches deep dig fee applies. Recommended
Boost additive CCLS additive,Installing a riser.
6. System Pumped By:
Michael Graham
Vehicle License Number
Name
Wind River Environmental, LLC, 577 Main Street, Ste #1i0, Hudson, MA 01749
Company
7. Location where contents were disposed:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
11/09/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
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