HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1155 SALEM STREET 12/14/2020 Commonwealth of Massachusetts vile
H ;F City/Town of North Andover 4bl.►�IrO 744
System Pumping Recordpry. oRrti
!4' Form 4 OFp�RT N�'s
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.
A. Facility Information
1. System Location:
1155 Salem Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Sam D'Antonio
Name
1155 Salem Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786851123
Telephone Number
B. Pumping Record
1. Date of Pumping 11/27/2020 2. Quantity Pumped: 1500.0000
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:
sludge. Baft baffies arre intact. Main line Clear. NO filLU-1 i5 PLU5ent On tile tanki
current tank is not designed to be used with a filter. Cover(s) secured. Pumped
1500gallons. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Marcus Lark
Name Vehicle License 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
11/27/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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