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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 BRUIN HILL ROAD 11/1/2021 rr7c,EIVED Commonwealth of Massachusetts . .� City/Town of North Andover IVIJ� u OF NORTH System Pumping Record TO HEATHDEPART'MENT ANgovER 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 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: 49 Bruin Hill Road Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Danny Azzarello Name 49 Bruin Hill Road Address(if different from location) North Andover MA 01845 City/Town State Zip Code 7815895089 Telephone Number B. Pumping Record 1. Date of Pumping 09/22/2021 2 Quantity Pumped: 1000.0000 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: Sr,stewz Opel;aLlng Normal r le of M a ate top—solids Moderate bottom studge. Both bafftes are intact. Main linte eiecir- No filt— ja---t ull tile tank—, current tank is not designed to be used with a filter. over s secured. Pumped 1000 gallons. 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: 163 Western Ave, Gloucester, MA 01930 09/22/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1