HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 456 SALEM STREET 4/5/2021 Commonwealth of Massachusetts
�1 City/Town of �-��
_ I North Andover 0 Cs ,� Cw0
1`I System Pumping Record
/ Form 4 :o a
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:
456 Salem Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Janelle Barrow
Name
456 Salem Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787294637 xcell
Telephone Number
B. Pumping Record
1. Date of Pumping 03/19/2021 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑X No If yes, was it cleaned? 0 Yes No
5. Observed condition of component pumped:
System Operating Fine Norma I water 1-01-7cU- Moderate top Sol ids Moderate bottom
siudge. Buth baffles axe intaut. Main Time Clear. Na ftit:ex is pxesent on tile rank;
current tank is not designed to be used with a filter. Cover(s) secured. Pumpe
1500gallons. Recommended No Recommendation.
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
03/19/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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