HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1980 TURNPIKE STREET 1 3/10/2021 :.XvEo
Commonwealth of Massachusetts R
City/Town/Town of
y North Andover NO
System Pumping Record P��M�N�
. � Form 4
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:
°80_ Turnpike Street
Address -
A:o-th Andover MA 01845
- ---
City/Town Slate _ Zip,Cod_ --
2. System Owner:
Affini ty Realty Prgprrty_Managment
Name _
63 Atlantic Avenue
Address(if different from location) _ -
Boston MA 02110
—_
City/T Stateown - _-�
Zip Code
9786949399
TeNphone Number
B. Pumping Record
1. Date of Pumping o2/15/2021Date - 2. Quantity Pumped: 3500.0000 _
Gallons
3. Component: Cesspooi(s) 0 Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes a No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
t ormal-water Level -4-in -bQ"QTi-sludge.-tin-tpp-s baff£1�s_.are_izcact
• e
e used with a i ter. over s secure a.
6. System Pumped By:
Robert Herrick
Name Vehide License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
02/1 5/20.21
Signature of Hauler - - -
Date
Signature of Receiving Facility(or attach facility receipt) Date
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