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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 97 LOST POND LANE 7/26/2021 RECEIVED Commonwealth of Massachusetts JUG 6 2021 City/Town Of North Andover TOWN OF NORTH ANppVER System Pumping Record HEALTH DEPARWENT 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: 97 Lost Pond Lane Address North Andover MA 01845 CityfTown State Zia Code 2. System Owner: Louise & Gary Daubresse Name 97 Lost Pond Lane Address(if different from location) North Andover MA 01845 Cityrrown State Zip Code 6179476904 Telephone Number B. Pumping Record 1. Date of Pumping 06/04/2021 _ 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 FNo If yes, was it cleaned? ©YesEj No 5. Observed condition of component pumped: System Qp�rating Fine Nc,�rwal Water le"al Mnd�rata top Qn1jdQ Moderate b0tt= sludge. Both baffles cleaned as needed. over s secured. Removed 1000 galions. Recommended Boost additive,CCLS additive. 6. System Pumped By: Robert Herrick Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA 06/04/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1