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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 131 CRICKET LANE 11/1/2021 RECEIVED Commonwealth of Massachusetts NI IV p City/Town of North Andover TOWN OF NORTH I ANDUVE. a System Pumping Record HEALTHDEPARTME,d 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: 131 Crickett Lane Address North Andover MA 01845 Cityrrown State Zio Code 2. System Owner: Rex Pa-i ela Name 131 Crickett Lane Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9788524163 xCell Telephone Number B. Pumping Record 1. Date of Pumping 09/16/2021 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: sludge. Butli baffies axe intact. Main line elcar. ftlter is pxeseilt and licts be-en cleaned as needed. over s secured. Recommended oost 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 09/16/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1