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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 NORTH CROSS ROAD 11/1/2021 RECEIVED Commonwealth of Massachusetts NOV 0 1 2021 City/Town of North Andover TOWN OF NORTH ANDOVER 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: 64 North Cross Road, Address North Andover MA 01845 City/Town State Zio Code 2. System Owner: Kris Alexander Name 64 North Cross Road, Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9783822951 x Telephone Number B. Pumping Record 1. Date of Pumping 09/30/2021 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: S stem operating Fine Normal water la"al Nnderate to gnlids Wpderate bottom current tank is not designed to be used with a tilter. 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 r-!a 09/30/2021 ignature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1