HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 336 SHARPNERS POND ROAD 9/7/2021 Commonwealth of Massachusetts
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 determine the form
they use.The System Pumping Record must be submitted to the local Board of Health or ot�r��f�prQ4i �ity within 14
days from the pumping date in accordance with 310 CMR 15.351. fK{GG�v+GG
A. Facility Information
1. System Location: HANppvER
336 Sharpners Pond Road jov,OF NORT tAoRl 'j,,,J
Address — — �
North Andover _ MA 01845
City/Town State Zia Code
2. System Owner:
Ellen & Brian Fitzgerald
Name
336 Sharpners Pond Road
Address(if different from location)
North Andover MA _ 01845
City/Town State Tap Code
9782586272 xhome
Telephone Number
B. Pumping Record
1. Date of Pumping 05/10/2021 2. Quantity Pumped: 1500.0000 _
Date Gallons
3. Component: Cesspooi(s) 0 Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? R Yes No
5. Observed condition of component pumped:
System operating Pinp Y'Ormal WAt-�r leAr'.1 Moderate top anlids Mod—a— bottom
l=
cleaned as needed. Covers 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:
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
05/10/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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