HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 LACONIA CIRCLE 3/21/2022 �jECEtVED
Commonwealth of Massachusetts
City/Town of North Andover MAR 212022
System Pumping Record Oa1h►ANpOVEE
y< Form 4 TO EA4jH'DEpARTMENj
M DEP has provided this form for use by local Boards of Health.Other forms may be used,but the informs on 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:
80 Laconia Circle
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Marianne Jenkins
Name
80 Laconia Circle,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6179740002 x
Telephone Number
B. Pumping Record
1. Date of Pumping 12/23/2021 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank ❑Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑X Yes No If yes, was it cleaned? ❑X Yes No
5. Observed condition of component pumped:
System Operating Fine Normal water l eval- .Maderate tQP solids madarat a bottom
sludge. Buth baffies cire tntdct. Matil tine Ctedr. Fttter is present: diid has been
cleaned as needed. over s secured. Removed 1500 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
12/23/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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