HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 638 FOREST STREET 6/7/2021 RECEIVED
Commonwealth of Massachusetts JUN 0 7 2021
Cit /Town of
y North ?:ndov=r TOWN OF NORTH ANDO R
u_
System Pumping Record HEALTH DEPARTMENT
Form 4
DEP has provided th.s 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 foram
they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14
days from the purping date in accordance with 310 Ch1R 15.351.
A. Facility Information
1. System Location:
638 -orest Street-
Address
North Andover MA 01845
CityfTown --
2. System Owner:
Steven and Stephanie Parkes
Name
638 Forest Street
Address(if different from location) —
North Andover MA 01845 _
City/Town State Zip Code
9787:5.s_
387- :::-:or^:e
Telephone Number
B. Pumping Record
05/18/2021 1500.0000
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Component: F1 cesspool(s) 0 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-Opararirg =ne.—xoz Ltosa
5tudge. Both, bafftes- ±zotaCt. Mawr line ctedr. - thank;
current tank is not designel to be used wit a filter. Cover s) secured.-- —Pumped
_-------- .
:3009allons. Recommended Boost additive.
6. System Pumped By:
Marcus 'ark
Name Vehicle Ucense Number
Wind R_v—r Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
Greater Lawrence Sanitarz District : 240 Charles Street , North Andover, MA
05/18/2021
S.cnature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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