HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 63 CROSSBOW LANE 5/13/2021 a _ Commonwealth of Massachusetts RECEIVED
a' a City/Town of i�or`h �t;dover ��� A'"���
_ System Pumping Record »¢F�rURITi+ A
� 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:
63_-_Crossbow Lane
Address
North Andover _ MA 01845
CityfTown State
2. System Owner.
n Duffy ---
Name
63 Crossbow Lane --
Address(if different from location)
North_ Andover- _ MA 01845
City/Town State Zip code
9786830731 xHome
Telephone Number
B. Pumping Record
-71 0000
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: cesspool(s) FX-] septic Tank ❑ Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? a Yes No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
system-J�+era..izg i-i"e_- Iia:ual--Wa
Z-1-udge --Soto-baff3us-are—intact. Mat, Fi3ter-fs-gre -
c vine as nee a over s secured. Remove ga ons. ecotnrr�ien e3 Boost
additive,CCLS additive.
6. System Pumped By:
Robert Herrick
Nati1B Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110,_Hudson, MA 01749
Company
7. Location where contents were disposed:
163 Western Ave, Glouc ster, MA 01930
04/16/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date _
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