HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 CHRISTIAN WAY 1/25/2021 RECEIVED
Commonwealth of Massachusetts JAN 2,5 20?1
City/Town of North Andover TOWN OF NORTH ANDOVER
System Pumping Record
HEALTH DEPARTMENT
a' Form 4
DEP has provided this farm 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:
101 Christian Way
Address
North Andover MA 01845
City/rown State Zip Code
2. System Owner:
Kevin Hanley
Name
101 Christian Way
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786827926 xHome
Telephone Number
B. Pumping Record
1. Date of Pumping 12/09/2020 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: cesspool(s) FjX-j Septic Tank ❑ Tight Tank ❑Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? Yes D No
5. Observed condition of component pumped:
System Operating Fine Nnrmal water leval H�avy top qn1jHs H-avy hnti-nm Q111eig'.
Butli baffles an- intact:. Main line Clear. No fitter is present on tlie 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
12/09/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
,.. .... _Yrd '�'" .y: �'.. „ '�a 4E. ". �Z �Ff3&' t -:� �r 't.-.rf� — I� '� a �s
.. �
.. w,
..�....� _. I .�.�.
aaa �,g, ��Ifssa�c-�r-5°S - M �..,����� .,,• ��py' .�.;:.�- 'sa �� :�t. u� ..
.. �..�
,. .. .: