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
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