HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1499 SALEM STREET 4/5/2021 C'EVEIVED
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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:
1499 Salem Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Ashish Shah
Name
1499 Salem Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787254887
Telephone Number
B. Pumping Record
1. Date of Pumping 03/15/2021 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) o Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑X Yes ❑ No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
System operating Fine High water level mnde�ate top 2nlic!2 bottom
t5tudge. Butir baffles cire intact. Mciin line Ctecu. Fttter ts present and licus beErrr--
cleaned as needed. Cover(s) secure T Waters high solids moderate sludge moderate
recommend boost and ccls additives Recommended Boost additive,CCLS additive.
6. System Pumped By:
Ricky Perez
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
03/15/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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