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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 GRAY STREET 7/26/2021 mECEIVED 'LN Commonwealth of Massachusetts City/Town of JUL 2 6 ��21 North Andover System Pumping Record TCWNOFNo"", DOVER Form 4 HEp,LTH DEPARTMENT 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 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: 90 Gray Street Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Cindy Brandt Name 90 Gray Street Address(if different from location) North Andover MA 01845 City/Town State Zip Code 7818971755 Telephone Number B. Pumping Record 1. Date of Pumping 06/22/2021 2. Quantity Pumped: 1500.0000 Date Gallons 3. Component: Cesspool(s) © 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 operating FJne NQ'Mal water le"el uaavrtop snlids Moderate bottom siudge. Buth baffte.'s are intact. Maill line Ciedr. NU ftiter is Present all the tank, current tank is not designed to be used with a fiiter. over s secured. Pumped 1500gallons. Recommended CCLS additive. 6. System Pumped By: Marcus Lark Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835 06/22/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1