HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1024 TURNPIKE STREET 4/5/2021 Commonwealth of Massachusetts RECEIVED
�F City/Town of North Andover APR U 707.1
r-' 1 System Pumping Record
TOWN OF NUR1H ANDUVE
Form 4
HEALTH DEPARTMENT
`?g 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:
1024 Turnpike Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Mark Fagan
Name
1024 Turnpike Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9173713201
Telephone Number
B. Pumping Record
1. Date of Pumping 03/11/2021 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 11 Yes 0 No If yes, was it cleaned? FYes ❑ No
5. Observed condition of component pumped:
current tank is not designed to be used with a filter. Cover(s) secured. Remove
1500 gallons. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Robert Herrick
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
03/11/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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