HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 SUNSET ROCK ROAD 5/13/2021 : \ Commonwealth of Massachusetts 1peof
City/Town of North Andover MAy 13 ' 421
System Pumping Record oFNpR�NPNo�`
3y r 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 Ch1R 15,351.
A. Facility Information
1. System Location:
66 Sunset Rock Road
Address
North Andover MA 01845
6 own State
2. System Owner:
Steve Marshall_
Name
66 Sunset Rock Road
Address(4 different from location)
North Andover MA 01845
City/Town State Zip code
9786853031 xhom!q
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) [J—W] 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:
Lo zz)_:. a. -Moderate-bo
-sludge_ Buth bafflare -n .litreCYear:-lv' s rrk;
cdrrent tank is not-de--signed not -de--signed to be used with a filter. over s secure umpea
1500gallons. Recommended Boost additive,CCLS additive.
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 L-::rence Sar. . tary District : 240 Charles Street , North Andover, MA
04/15/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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