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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1200 SALEM STREET 7/26/2021 RECEIVED Commonwealth of Massachusetts JUL 6 2021 City/Town of North Andover OF NORTH a System Pumping Record TD HEALTH DEPARTMENTER Form 4 M _ 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: 1200 Salem Street Address North Andover MA 01845 City/town State Zip Code 2. System Owner: Kathleen Hadar Name 1200 Salem Street Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9788848384 xKate Telephone Number B. Pumping Record 1. Date of Pumping 06/01/2021 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 ElNo 5. Observed condition of component pumped: q�rstQm operating pjn2 Nn waj s A*er1e- 1 M Cjerate top solids Moderate hart= studgre. Buth baffites dre intact. Main line etear. No filt— F--t U11 the tank-'— current tank is not designed to be used with a filter. 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: 163 Western Ave, Gloucester, MA 01930 06/01/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1