HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 81 SAW MILL ROAD 4/5/2021 Commonwealth of Massachusetts RECEIVED
{ City/Town of North Andover APR 0 Zp21
System Pumping Record NOR�H000'4R
Form 4 l4W �NpEPPRjMEN
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:
81 Sawmill Road
Address
North Andover MA 01845
City/Town State _ Zip Code
2. System Owner:
Lisa Perella
Name
81 Sawmill Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9784018788
Telephone Number
B. Pumping Record
1. Date of Pumping 03/08/2021 _ 2. Quantity Pumped: 2500.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? Yes R No
5. Observed condition of component pumped:
tank;System not Operating Fine High water 1-0'rc�j - W.-)d0rate top solids Heavy I)GttQm
studge. Batti bafftet5 d.Le intact. Main tine Ctea-r. Nu filter is pre5ent on the
current tank is not designed to Be-used wiEh a filter. Cover(s) secured. Pumpe
2500 gallons. Recommended Boost additive,CCLS additive,Pump Repairs.
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:
163 Western Ave, Gloucester, MA 01930
03/08/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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