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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 980 FOREST STREET 10/12/2021 (3) RECE, SD Commonwealth of Massachusetts City/Town of North Andover ! System Pumping Record " IOWA DEPARSME Form 4 N M 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,,heck with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the to-. _Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CM 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: 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 vinQ Normal- wate, Heavy top sGiids Heavy hottom sludge Buth bafflt�s dre intaut. Mdizi tine Ctear. Fitter is present drid has been cledned as needed. Cover s secured. Title 5 inspection 1500 gal compartment tank proper level inlet and outlet tee's in good condition with a Zabel filter, tank is structurally sound, 1000 gal pump chamber proper level floats pump and alarm in working order, D box @ 0" liquid level good 4 lines to a leaching field, box is in n.9 n .i;+; cvc+cm ,n rur,rYi nn nrrlor C! Q�m fi��cc Acnnmmcnr7cA Ar,nct 6. System Pumped By: ,,1 >• Gerardo Valentin Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: 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