HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 295 CANDLESTICK ROAD 9/7/2021 Commonwealth of Massachusetts
W 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 termine the form
they use.The System Pumping Record must be submitted to the local Board of Health or i only within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location: TOWN OF NtIF81 �
295 Candlestick Road 6EAJT
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Sergey Beddenin
Name
295 Candlestick Road
Address(if different from location)
North Andover MA 01845
City/Town state Zip Code
6174290294 xHome
Telephone Number
B. Pumping Record
1. Date of Pumping 05/26/2021 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: cesspool(s) FJW� 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:
R
sludge. Both baffles dLe intaut. Main iine elear. No filter is pLeselit: U11 the tal1k;
current tank is not designed to be used with a filter. Covers secured. Pumped
1500gallons. Recommended Boost additive,CCLS additive.
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:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
;'g 05/26/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1