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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 314 REA STREET 7/26/2021 RECEIVED Commonwealth of Massachusetts JUL 2 6 2.021 City/Town of North Andover TOWN OF NORTH ANDOVER System Pumping Record 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 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: 314 Rea Street Address North Andover MA 01845 Citylrown State Zio Code 2. System Owner: Amy Cianciaruso Name 314 Rea Street Address(if different from location) North Andover MA 01845 Cityrrown State Zip Code 9789798301 Telephone Number B. Pumping Record 1. Date of Pumping 06/21/2021 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: S�,stom oporat-ing Pine NQrmai water level Moderate top solids made'at. h�ttom sludge. Butli baffies are intact. Main iine elear. ftitur is prestrit and lias been cleaned as needed. over s secured. Recommended Boost additive,CCLS additive. 6. System Pumped By: Michael Graham 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 06/21/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1