HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 OLD CART WAY 12/14/2020 i
Commonwealth of Massachusetts AFC V�O
City/Town of North Andovero
System Pumping Record
.� Form 4
w 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:
100 old Cart Way
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
John and Lynn Erb
Name
100 Old Cart Way
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9783760393 xCell
Telephone Number
B. Pumping Record
1. Date of Pumping 11/17/2020 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) FXJ Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
System Operating Tine Normal water level Moderate top solids Moderate
sTudge. Butli baffies are intdcr— Main line Clear. No filter i5 present an tlie tank;
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:
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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