HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 236 SUMMER STREET 6/7/2021 Commonwealth of Massachusetts
i
r City/Town of Norm Andover
System Pumping Record
Form 4
`�•-�_;' DEP has prov.ded this form for use by local Boards of Health.Other forms may be used,but the information mus
substantially the same as that provided here Before using this form,check with your local Board o the form
they use.The System Pumping Record must be submitted to the local Board of Health or other appng authority within 14
days from the pumping date in accordance with 310 CLIR 15.351.
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A. Facility Information OFNORIHANDOVER
1. System Location: TO EALIHpEPARIMENI
, -
. �o S der_-_Street
Address
North Andover MA 01845
Cityfrown State _-- Zip f ode
2. System Owner.
; --'a Kooken M _
Name
236 Summer Street
Address(if different from location)
North Andover MA 01845
City/Town -- State Zip Code
7812589273
Telephone Number
B. Pumping Record
05/12/2021_ 1500.0000
1. Date of Pumping pate — 2. Quantity Pumped: Gallons _
3. Component: Cesspool(s) F)CI Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes a No If yes, was it cleaned? R Yes No
5. Observed condition of component pumped:
Syy-srzm--Crrerar nc} a:. 1-a :a Ddoderax h t:Lom
-s1-udqe-.--Bcth-bat--' -411,tatUt. ..
current tank is not esigne to a use wit a i ter. over s secured. Remove
:500 gallons. Recommended Boost additive,CCLS additive.
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 Sanitarr�District 240 Charles Street North Andover, MA
05/12/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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