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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 540 BOXFORD STREET 2/10/2022 RECEIVED Commonwealth of Massachusetts City/Town of North Andover FEB 10 2022 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT M 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: 540 Boxford Street, Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Adam Bolduc Name 540 Boxford Street, Address(if different from location) North Andover MA 01845 City/Town State Zip Code 6179229500 x Telephone Number B. Pumping Record 1. Date of Pumping 10/26/2021 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 0 No If yes, was it cleaned? ©Yes ❑ No 5. Observed condition of component pumped: System Operating Fine Normal i,Tatar leval_ Moderate top solids modarate hnttom beeir— 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: 163 Western Ave, Gloucester, MA 01930 10/26/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1