HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2163 TURNPIKE STREET 5/17/2021 Commonwealth of Massachusetts
;F City/Town of North Andover
=i System Pumping Record
Form 4
-s 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:
2163 turnpike street
Address
North Andover MA 01845
City/Town State _ Zip Code
2. System Owner:
Isabella Bergstrom
Name
2163 turnpike street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
7818662099 xIsabel _
Telephone Number
B. Pumping Record
1. Date of Pumping 04/05/2021 __ 2 Quantity Pumped: 1500.0000 -
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
System aperatincj Fine Nc�rmal watLi�r lelral- Moderate top solids mcdQrate hnttom
sludge. Botli bdffles are intact. Main line Clear. No filter is pre5ent uii tile tankr
current tank is not designed to be used with a filter. Covers secured.
Recommended Boost additive,CCLS ,additive.
6. System Pumped By:
Michael Graham
Name Vehicle License 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
04/05/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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