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HomeMy WebLinkAboutSepitc Tank - Septic Pumping Slip - 292 GRANVILLE LANE 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: 292 Granville Lane Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: John Laspisa Name 292 Granville Lane, Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9788095633 x Telephone Number B. Pumping Record 1. Date of Pumping 09/08/2021 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 0 No If yes, was it cleaned? R]Yes No 5. Observed condition of component pumped: sludge. Both baffles are intact. m�tjjj jiliv cie_L-L. Filter is present and has beem cleaned as needed. Cover s secured. Recommended Boost 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: Greater Lawrence Sanitary District 240 Charles Street North Andover, MA 09/08/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1