HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 315 SOUTH BRADFORD STREET 3/21/2022 aEcvjel'
Commonwealth of Massachusetts MAR 21 JW
City/Town Of North Andover SH ANpOVE�
System Pumping Record V0WNoTHOEpc�cME"�
Form 4 HEA
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:
315 South Bradford Street
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Smolak Farms
Name
315 South Bradford,
Address(if different from location)
North Andover MA 01845
Cityrrown State Zip Code
9786826332 x
Telephone Number
B. Pumping Record
1. Date of Pumping 02/09/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) fjk� 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:
Taw .later ;e'lel ai-n bottom sludge Oin to solids Main ling Clear No filter is
JJLt!5U1Lt U11 tile tCLILk. curLent tank is not designed to be used wttli a ftl:ter.
Cover s secured. No 3rd party paperwork i e . Removed ail gallons.
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
02/09/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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