HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 MILL ROAD 5/17/2021 may, Commonwealth of Massachusetts
^ City/Town of North Andover
h System Pumping Record
Form 4
r � Y
DEP has provided this form for use b local Boards of Health.Other forms may be used,but the information must be
p
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:
30 Mill Road _
Address
North Andover _ MA 01845
Cityrrown State Zip Code
2. System Owner:
Alan Jordan
Name
30 Mill Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9783942070 xcell
Telephone Number
B. Pumping Record
1. Date of Pumping 04/06/2021 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 not operating Fine High water level Moderate tGP solids Moderate hottom
5tudge. Both bdffles are inta.ct. Main line Cieaz. No fittex is present an the tank,—
current tank is not designed to be used with a filter. Covers secured. Remove
over 1500 gallons. Recommended No Recommendation.
6. System Pumped By:
Robert Herrick
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
04/06/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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