HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 236 SUMMER STREET 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 other approving authority within 14
days from the pumping date in accordance with 310 CMR 15.351. RECEIVED
A. Facility Information I�
1. System Location: SFP Q 1 O LAI
236 Summer Street NOFNORIHANDOvER
.J
Address HEALTH DapARWE
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Karla Kooken
Name
236 Summer Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
7812589273
Telephone Number
B. Pumping Record
1. Date of Pumping 05/12/2021 2. Quantity Pumped: 1500.0000
Date Gallons
1 Component: ❑ Cesspool(s) ❑X Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes 0 No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
system npPrating V�ne Y'nymaj wat�r lelrel Light top soli-is Moderate bcttnM
sludge. Both baffles dLe intact. Main iine Na fil-tei is pns6--nt on the tankf
current tank is not designed to be used with a filter. Cover(s) secured. Remove
1500 gallons. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Robert Herrick
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
05/12/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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