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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 790 FOREST STREET 5/13/2021 Commonwealth of Massachusetts RECEIVED City/Town of 1, h At,d:v� MAY 1 3 %'G21 System Pumping Record TOWN OF NORTHANDUVc, 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: 790 Forest Street Ad - -- _ dress North Andover i;:; 01845 City/Town State Zip C.4de 2. System Owner. Pam & Paul Guerrieo _-_- _ ---_- Name 790 Forest Street _ - --- Address(if different from location) North Andover IAA _. 01845 — City/Town--- ------ _ State Zip Code 9786832404 xF,--me Telephone Number B. Pumping Record 04/23/2021_ 1000.0000 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap Other(describe): 4. Effluent Tee Filter present? M Yes No If yes, was it cleaned? a Yes No 5. Observed condition of component pumped: �rsLem--gpe ra�;Fine.--ATars:+a1-�.aLc r-.-2Eue1_---idodwaz.�;.cap-sal.ids-.-Mcadexa�e- ut3ge—BBth--tratftes--are-zntact-Main _F tt-er-is present — cTeneec —asn-eededCover s secure umped qa ons. Recommen a oost 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: eater r. Lary District 240 Charles Street North Andover, MA 04/23/2021 _— Signature of Hauler Dade Signature of Receiving Facility(or attach facility receipt) Dade 15form4.doc• 1112 System Pumping Record•Page 1 of 1