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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 546 FOSTER STREET 11/1/2021 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record 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: 546 Foster Street Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Deborah Moore Name 546 Foster Street, Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9785027683 x Telephone Number B. Pumping Record 1. Date of Pumping 09/20/2021 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: ^at ng Fjn� Narmal watPrle'rel Tight top Sn1i11c Mnderate hnttnm sludge. Butli baffles ctre intact. Maiii lillu eit�cll- NO filter is present an tlie tailk, current tank is not designed to be used with a filter. over s secured. Remove 1000 gallons. Recommended Boost additive,CCLS additive. 6. System Pumped By: Robert Herrick 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 09/20/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1