HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 BOSTON STREET 5/13/2021 Commonwealth of Massachusetts �►00P
City/Town of
:orch Andcve:- y
System Pumping Record
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:
1.65 Boston Street
Address
North Andover Mil 01845
City'Town Do Code
2. System Owner
E'ric Ly:,ci,__ --------.__.- - _.
Name
65 Boston Street _ -_
Address(if different from location)
North Andover.__ MA 01845
Citylfown — — State lip Code
9788076348
Telephone Number
B. Pumping Record
1. Date of Pumping 04/12/2021__Date 2. Quantity Pumped: G ions 0000__
3. Component: Cesspool(s) � Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes 0 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
S}rszem.-OYara:.isig-F•ins.-�Iarrial--kar.e-r--leue.i-.tioder-�.ce-itog�olids_-Moderate---h�>r:.cm--
sYudge:-Sour baff3esire-intact—Nta' o fi3cez 1
current tank is not esigne to a us�it a i ter. over s) secure .
Recommended Boost additive,CCLS additive.
6. System Pumped By:
-chaei Graham
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
m Copany
7. Location where contents were disposed:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
04/12/2021
Signature of Hauler Dafe
Signature of Receiving Facility(or attach facility receipt) Date
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