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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 ROCKY BROOK ROAD 10/12/2021 RECE,VED Commonwealth of Massachusetts. City/Town of North Andover System Pumping Record TO OFNORTHANDOVER Form 4 H�I.TH DEPARTMENT 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. A. Facility Information 1. System Location: 60 Rocky Brook Road Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Sonali Sattathy Name 60 Rocky Brook Road Address(if different from location) North Andover MA 01845 City/Town State Zip Code 7813151431 Telephone Number B. Pumping Record 1. Date of Pumping 08/05/2021 2. Quantity Pumped: 1500.0000 Date Gallons 3. Component: Cesspool(s) © Septic Tank Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? Yes © No If yes, was it cleaned? ❑Yes ❑ No 5. Observed condition of component pumped: System Operating wine Normal water le-1 NGdera-to top solids Moderate bottom current tank is not esig—nedto be used w1th, a. filter. Cover s secure Remove 1500 gallons. Recommended Boost additive,CCLS additive. t (G 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 2 08/05/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1