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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 267 OLD CART WAY 11/1/2021 RECEIVED Commonwealth of Massachusetts N0V 0 1 ?f 1 City/Town of North Andover TOWN OF NORTH ANDOVER a System Pumping Record HEALTH DEPARTMENT 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: 267 Old Cart Way Address North Andover MA 01845 City/town State Zip Code 2. System Owner: Lisa Reichlen Name 267 Old Cart Way Address(if different from location) North Andover MA 01845 City/Town State Zip Code 6033611212 Telephone Number B. Pumping Record 1. Date of Pumping 09/29/2021 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: c,� Operating Eine Normal Water level HOA3.zy to solids MAderate bottom current tank is not designed to be used with a tilter. over s secured. Pumped 1500gallons. Recommended No Recommendation. 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: HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835 09/29/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1