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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 157 LANCASTER ROAD 7/26/2021 RECEIVED Commonwealth of Massachusetts 202.1 City/Town of North Andover JUL System Pumping Record TOWN OF NORTHANDOVER HEALTHH 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: 157 Lancaster Road Address North Andover MA 01845 Cityrrown State Zip Code 2. System Owner: Richard Tokwicz Name 157 Lancaster Road Address(if different from location) North Andover MA 01845 Citylrown State Zip Code 9786890688 Telephone Number B. Pumping Record 1. Date of Pumping 06/28/2021 2. Quantity Pumped: 1000.0000 _ 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: studge. Both baffles are intact. mjill j:j:11t:! ejucL. Nu fjj:tt:�r is present on the tank, current tank is not designed to be used with a filter. over s secured. Pumped 1000 gallons. Recommended Pump Repairs. 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: NEMO Yard: 54 Knox Trail, Acton, MA 01720 06/28/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1