HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 544 FOSTER STREET 6/7/2021 Commonwealth of Massachusetts
City/Town of 1,7 cr-h andoyer
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 HeaM the form
they use.The System Pumping Record must be submitted to the local Board of Health or other approving f on within 14
days from the pumping date in accordance w,1h 310 CMR 15.351.
A. Facility Information
1. System Location: TOWN OF
NORTHANDO�ER
HEALTH DEPARTMENT
545 zoster Street_ -
Address
North Andover MA 01845
..._
CityJTc;:=n State _.. Zlp_Code
2. System Owner:
_Tun
Name
544 roster Street
Address(if different from location)
North Andover NIA 01845
City/Town State Zip Code
61 750151:` ::ce!_ _
Telephone Number
B. Pumping Record
05/17/2021 1500.0000
1. Date of Pumping pate 2. Quantity Pumped: Gallons _
3. Component: Cesspools) Q Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes 0 No If yes,was it cleaned? Yes No
5. Observed condition of component pumped:slvd;;B7. -+3oth baffles-are-�'rta -ea-r _ -gre5ent on-Er yank;
current tank is not esignedtto 5e7uied with a i ter. C ovex s secu- u-re-d:�Remove-cc —
1500 gallons. Recommended No Recommendation. � -
6. System Pumped By:
Robert Herrick _
Name Vehicle License Number
Winn River Environmental., LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company �
7. Location where contents were disposed:
Gre = r:ce Sanitary District 240 Charles Street , North Andover, MA
05/17/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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