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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 305 MIDDLETON STREET 7/26/2021 Commonwealth of Massachusetts RECEIVED City/Town of North Andover j�)L 6 2021 -- System Pumping Record TOWN OF NOW HANDOVER Form 4 HEALTH DEPARTMENT "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: 305 Middleton Road Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Commonwealth Dept. DCR Northeast Region Name 25 Shattuck Street Address(if different from location) Lowell MA 01852 City/Town State Zip Code 9789372092 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: Normaj- �,;atari 2in hc)trtom sludge Ain top solids Seth baffler are intact Maill tine _Cteaz. No fttter is present all tile tanki curnant tank is nut des±yiied tu e used with a filter. over s secured. No 3rd party paperwork i e . Pumped gallons. 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