HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 ACADEMY ROAD 1/25/2021 Commonwealth of Massachusetts RECEIVED
City/Town of North Andover BAN p5 2021
System Pumping Record TOWN OFNORrH
r ANDOVER Form 4 HEALTH DEPARTMENT
EPq TENTMENT
e,
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:
83 Academy Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Kathy Stevens
Name
83 Academy Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786835522 xHome
Telephone Number
B. Pumping Record
1. Date of Pumping 12/15/2020 2. Quantity Pumped: 2000.0000
Date Gallons
3. Component: ❑ cesspool(s) ❑X 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:
System Operating Fine Normal water I-evel— T-Jght top goliris bdodej:ate bottom
. Main line Clear. No filtei is prestnit on tint tank;
current tank is not designed to be used with a filter. Cover(s) secured. Pumped
2000 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:
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
12/15/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
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