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HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 10 JERAD PLACE 7/26/2021 RECEIVED Commonwealth of Massachusetts JUL 2 6 2021 City/Town Of North Andcver TOWN OF NORTH ANOOVER System Pumping Record HFALTHDEPARTMENT 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: 10 Jerad Place Address North Andover MA 01845 City/rown State Zip Code 2. System Owner: Michael Levin Name 10 Jerad Place Address(if different from location) North Andover MA 01845 City/Town State Zip Code 6178385316 Telephone Number B. Pumping Record 1. Date of Pumping 06/14/2021 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;' 'i a peiatincj i:ine Normal- wate, to l macje�ate top solids Moderate bottom sludge. Butti bafflus cire intact. M&ji, jjjjt2 eje_,.L. Fiiter is present 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 4110, Hudson, MA 01749 Company 7. Location where contents were disposed: HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835 06/14/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1