HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 650 FOREST STREET 6/7/2021 ram, Commonwealth of Massachusetts
City/Town of
System Pumping Record
F� 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 farm
they use.The System Pumping Record must be submitted to the local Board of Health or other approving autho'1 +it�14
days from the pumping date in accordance with 310 CMR 15.35E gFGE v G
A. Facility Information
1. System Location: �H P 'D()'4
0F.AO
Address N�L�
North Andover MA 01845
City/Tow,niMe
2. System Owner:
Robert/Pt i cia Gohr ----- _.
Name
650 Fare_: - ,-
Address of different from location)
North Andover 01845 --
CityrTown F T State Zip code
5082659213_xcell
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: 17 cesspool(s) Q Septic Tank R Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes � No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
3�st�-C��aL�..� :;ne.—::or,«al.._�ar_c:r--?eue.L_—Ddodeta�....�z>—salmis..--PdaBera:.�-baLL�ra--•-,--,-
S�IIt�yS—EtLtt _3 I'$z,"34M is tzict. 1J.151CT—SSPT�'SE'IIi^C77I
eurrent tanks not designeetto`3 a use wit a i ter. over s) secu—red-."
Reco:ttmended Boost additi,ve,CCLS additive.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind ztvironmental, LLC, 577 Main Street, Ste_ #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
163 Wes rn Ave, Gloucester, MA 01930
05/05/2021 --
Signature of Hauler n_ Date
Signature of Receiving Facility(or attach facility receipt) DIU
t5form4.doc• 11112 System Pumping Record•Page 1 of 1