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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 RALEIGH TAVERN LANE 7/26/2021 Commonwealth of Massachusetts RECEIVED City/Town of North Andover JUL 6 70 " - System Pumping Record Form 4 TCH�,LTH DEPARTMENT R 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: 70 Raleigh Tavern Lane Address North Andover MA 01845 City/Town State Zio Code 2. System Owner: Walter Soule, Name 70 Raleigh Tavern Lane, 978-478-7888 Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9784787888 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: ST.qtex opo atiagT; Normal wataY luvel Heavrtop solids Moderate bottom siudge. Buth bafftes are intact. Main iine Ciecir. Filter is present and tLas been 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 I,, 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