HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 TUCKER FARM 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 =Mority within 14
days from the pumping date in accordance with 310 CM 15.351.
A. Facility Information SEP Q 7 ?(Y,.
1. System Location: '
TOWN OF NORTH ANDUVER
91 Tucker Farm Road HFQITH DEPARTMENT
Address
North Andover MA 01845
City/Town State Zia Code
2. System Owner:
Pauline Hoenigsberq
Name
91 Tucker Farm Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9789850745
Telephone Number
B. Pumping Record
1. Date of Pumping 05/12/2021 2 Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Fjy�Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
studge. torli baffles dLe intact. Main tine elear. No ftiter ts pleselit On the tanki
current tank is not designed to be used with a filter. Covers 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:
163 Western Ave, Gloucester, MA 01930
,,_`,, 05/12/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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