HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 729 BOXFORD STREET 12/14/2020 o'c
Commonwealth of Massachusetts F0 c��1ezO
2020
;F City/Town of North Andover T 84 op�ORr�
System Pumping Record y��'°�RTMF°VFR
?% Form 4 Np
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:
729 Boxford Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Jeff Simmons
Name
729 Boxford Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786821784
Telephone Number
B. Pumping Record
1. Date of Pumping 11/17/2020 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) R Septic Tank Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? M Yes F)(j No If yes, was it cleaned? nYes No
5. Observed condition of component pumped:
sludge. BUtil bdffJ:t::ZJ ClLt.! illtact. Main line Clear. No filter is present on tlie tanki
current tank is not designed to be used with a filter. Cover(s) secured. System
assessment recommended . Pumped 1000 gallons. 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:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
11/17/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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