HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 74 WILLOW RIDGE ROAD 5/13/2021 RECEIVE®
,., Commonwealth of Massachusetts
City/Town Of North Andover
MAY � 3 'L.021
_ System Pumping RecordORI
O� °T"pEPARTME N
? 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 CNiR 15.351.
A. Facility information
1. System Location:
74 ;Willow Ridge Road
Address
.. : th Andover MA 01845
CitVrTown AM—— Zip Code
2. System Owner:
Jason Rotchs:. -i. _
NW" _.
74 N l 10-4 -Ridgee Road
_-_
Address(if different from location)
Nort.:. ?�ndover MA 01845
__.
CityfTown State Zip Coda
7816035712 xhome
Telephone Number
B. Pumping Record
04;15/2021 1500.0000
1. Date of Pumping - - -- 2. Quantity Pumped: -
Date Gallons
3. Component: ❑ Cesspool(s) F)CI 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}�ste�-L'}�ara-:.inc}-F-ine-. _i�toz;..al.-_wa.ter.-.l.euel,-Macieza e-:.oR--sa.i..:ds.--_Node -
-s31i dge.Both ba-f ff l e 5 die nta-ct:- r-i s-grese
current—tancTis not eszgne to a use wit a a ter. aver sf secure Pumpe
1500gall.ons. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Marcus Lark
Name Vehicle License Number
Wind River Environtrnen-,al, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
L: ::;ranee Sanitary 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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