HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 295 CANDLESTICK ROAD 6/7/2021 RECEIVED
Commonwealth of Massachusetts
JUG! 0 7 2021
City/Town/Town of
System Pumping Record TOWN OFNORTHANDOVM
y p g HEALTH DEPARTMENT
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 us,ng this form,check with your local Board of Health to determine the form
they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14
days from the pumping date in accordance with 310 CMR 15.351
A. Facility Information
1. System Location:
295 Candlestick Road
Address - --
North Andover MA 01845
Cityfrown late -
2. System Owner:
Sergey Beddenin
Name -
295 Candlestick R_a!
Address(if different from Iccation)
North Andover MA 01845
City/Town State Zip Code
6 __ . x_Home _
Telephone Number
B. Pumping Record
05/26/2021 15�G . �:�: �
1. Date of Pumping Date 2. Quantity Pumped: Gal!cns
3. Component: Cesspool(s) 0 Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑X No If yes, was it cleaned? Yes No
5. Observed condition of component purnped:
Sysees>:
sludge. Both baffles are intact. _ _ eserrt ,
current tank is not designed to be used with a filter. over s secured. Pumped-"—
._ --- -- - ---.
1500gallons. Recomtttended Boost additive,CCLS additive.
6. System Pumped By:
Marcus Lark
---------- —- ---- _
Name Vehicle License Number
Wind River Enviro ...;:-.-=:_, LLC, 577 S_r-et, Ste 4110, Hudson, MA 01749
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
f', 05/26/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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