HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 315 SOUTH BRADFORD STREET 3/21/2022 (3) RECENE`'
Commonwealth of Massachusetts MpR 212022
City/Town Of North Andover
System Pumping Record TOWN OF NORTHANDO
Form 4 HEALTH DEPARTMENT
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
City/Town State Zip Code
2. System Owner:
Michael Smolak Farms
Name
315 South Bradford,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9785002019 x
Telephone Number
B. Pumping Record
1. Date of Pumping 02/14/2022 2. Quantity Pumped: 0.0000
Date Gallons
3. Component: Cesspool(s) ❑X 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:
Normal water Qj-n bottom l d e Din top solidsBoth baffle baffle2 are intact
Main line eiea.L. No fttter is pLesent an the. tanki UULIellt tCLILk i.3 LlUt designed to
e used with a tiiter. Covers secured. No 3rd party paperwork i e . No alarm
sounding.
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:
%t 02/14/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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