Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1300 SALEM STREET 7/26/2021 RECENED Commonwealth of Massachusetts 3a 2 6 2021 City/Town of North Andover OF NORTHANDOVER TO HEp�TH DEPARTMENT a 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 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: 1300 Salem Street Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Mark Halbach Name 1300 Salem Street Address(if different from location) North Andover MA 01845 City/town State Zip Code 5089542785 xCell 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 Operatingcj n2 N rural water l el M d Ato tnp� nj IdS Moderate bottom cleaned as needed. over s secured. Pumped gallons. Recommended Boost additive,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