HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 PENNI LANE 3/21/2022 �L\ Commonwealth of Massachusetts P 2�tip'l1
City/Town Of North Andover
i, System Pumping Record oFt4o
Form 4 �ONEP�IN OEP
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:
102 Penni Lane,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Ana-Puala Fernandes
Name
102 Penni Lane,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6507430142 x
Telephone Number
B. Pumping Record
1. Date of Pumping 01/24/2022 2. Quantity Pumped: 2000.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑X No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System not Operating Fine Normal water level Mndarate tGp solids Moderate bottom
current tank is not designed to be used with a filter. Cover s secured. Remove
2000 gallons. Pump alarm sounding. Recommended Pump Repairs.
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
01/24/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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