HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 TUCKER FARM ROAD 6/7/2021 Commonwealth of Massachusetts
City/Town of -
oio: d o•ver
System Pumping Record
qr 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 *,a the form
they use.The System Pumping Record must be suomitted to the!ocal Board of Health or other apme w4hin 14
days from the pumping date in accordance with 310 CNIR 15,351.
A. Facility Information SUN
1. System Location: TOO OF 140pl jmeAl R ,
9-' 'ticker Farr;, Roan �THDEPAR
Address
North Andover %1A 01845
CityrTown ZpLcode
2. System Owner
lioenicisbera
Name
91 Tucker Farm Road
Address(if different from location)
Nortr__Andover _ Mir. 01845
City[Town State Zip code
9789850745
Telephone Number
B. Pumping Record
1. Date of Pumping -''5/12/2021 p_ 2. QuantityPumped: _500.D000 _
p g Date Gallons
3. Component: Cesspools) r-%—'l septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes a No If yes,was it cleaned? Yes No
5. Observed condition of component pumped:
S}rsze IIre=au:.g-e:re__ t - Feu -solids,-4�erat —
sludge. ath baff3es-are-t::tact.-V _ _ -tire-tank,
current ;.a'-a'nis not designe to be used with a filter. Cover(s) secure . Removed
1500 gal''ons. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, PLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
163 ---stern Ave, Gloucester, MA 01930
05/12/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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