HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 740 FOREST STREET 5/13/2021 RECEIVE®
Commonwealth of Massachusetts
— City/Town of Mort: ndo�Ter MAY 13 ;.021
System Pumping Record TOWN OF NORTH;
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:
740 ForeSt Street__
Address
North Andover MA 01845
CityfTown ate Code _
2. System Owner:
-Jane &_Stuart Thomg
Name
740 Forest Street —
Address(if different from location)
North---Andover- MA 01845 __
City/Town State Zip Code
9786827544
Telephone Number
B. Pumping Record
04 ./21/207,- 2 Quantity Pumped: 500.0000
1. Date of Pumping Date y p Gallons
3. Component: cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? 11 Yes No
5. Observed condition of component pumped:
}zy�ejA_nc�L-L3�er.aLig_Fna,--hloxmal--, er---level .ir3h:. --salidsT-6odea-ta-boLZ:osa-
-s-i�dge:�ttt_.ba�f3-e-s-are--izrta'ct—Main"`�irre-�ieaz':-tda�fi-ltsr-i�-fires
current Eank is not esigne to a use wi"t-h a fi tamer-`over s secure . Pumpe
1500gallons. Recommended Boost additive,CCLS additive. _T
6. System Pumped By:
Marcus Lark
Name Vehicle Lk*nse 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
04/21/2021
Signature of Hauler _ Date
Signature of Receiving Facility(or attach facility receipt) Date
t=,{nrnl4-HOC• 11 i 12
System Pumping Record•Page 1 of 1