HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 263 CANDLESTICK ROAD 5/17/2021 Commonwealth of Massachusetts
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City/Town of North Andover
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System Pumping Record
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:
263 Candlestick Road
Address
North Andover MA 01845
City/Town State _ _ Zip Code
2. System Owner:
Mary Nania
Name
263 Candlestick Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786856629 xhome
Telephone Number
B. Pumping Record
1. Date of Pumping 04/07/2021 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: cesspool(s) Fv_*1 Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? M Yes RNo
5. Observed condition of component pumped:
System Operating Fine Nc)rwal water lavel D4oderate top solids Moderate hc�ttam
current tank is not designed to be used with a filter. Cover(s) 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
04/07/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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