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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 305 MIDDLETON STREET 10/12/2021 REC�tveD Commonwealth of Massachusetts Ocl Clty/TOWn Of North Andover 0`Ntt0FJA0% _ system Pumping Record Form 4 r forms may be used,but the information must be DEP has provided this form for use by local Boards of Health.Othe 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. A. Facility Information 1. System Location: 305 Middleton Road Address MA 01845 North Andover State Zip Code City/Town 2. System Owner: T Ford Com an Name 124 Tenney Street Address(if different from location) MA 01833 Georgetown State Zip Code City/Town 5087264086 Telephone Number B. Pumping Record 08/26/2021 1000.0000 Date 1. Date of Pumping 2. Quantity Pumped: Gallons 3. Component: Cesspool(s) © Septic Tank Tight Tank Grease Trap Other(describe): 4. Effluent Tee Filter present? D Yes © No If yes, was it cleaned? 0 Yes No 5. Observed condition of component pumped: i ter. Cover s secure No r party paperwor i e . Remove a 1qui 6. System Pumped By: Robert Herrick Vehicle License Number Name Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835 08/26/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1