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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 980 FOREST STREET 10/12/2021 Commonwealth of Massachusetts FIEG�1VED City/Town of North Andover System PumpingRecord oR�HA"pO�ER Form 4 t0W�tTH r)EPARTMENT 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: 980 Forest Street Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Didier Thibaud _ Name 980 Forest Street Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9782080306 Telephone Number B. Pumping Record 1. Date of Pumping 08/19/2021 2. Quantity Pumped: 1500.0000 Date Gallons 3. Component: ElCesspool(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 Rine Normal- iaater I-eirel lXQC1@ratQ top sol-J-ds- Moderate battom� beerr­ cleaned as needed. Cover s secured. Recommended Boost additive,CCLS-additive. 6. System Pumped By: Michael Graham 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 08/19/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1