HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 650 FOREST STREET 9/7/2021 Commonwealth of Massachusetts
y City/Town Of north Andover
System Pumping Record
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 determjW the form
they use.The System Pumping Record must be submitted to the local Board of Health or other approvcing� in 14
days from the pumping date in accordance with 310 CM 15.351. �G
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A. Facility Information
1. System Location: �N PN0
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650 Forest Street �pWNDFNpEpPR�M�N�
Address
North Andover MA 01845
City/Town State Zia Code
2. System Owner:
Robert/Patricia Gohn
Name
650 Forest Street
Address(if different from location)
North Andover MA 01845
City/Town State Tap Code
5082659213 xcell
Telephone Number
B. Pumping Record
1. Date of Pumping 05/05/2021 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 ❑V No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
System Cperat4ng Fine Normal water level moderate top solids Mod—ate bottom
sludge. Buth baffies ci.Lu intact. Main tine elear . No filter is gresent on the tanko
current tank is not designed to be used with a filter. Cover(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
05/05/2021 _
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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