HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 TURNPIKE STREET 4/19/2022 RECE1VEL'
Commonwealth of Massachusetts APR 19 2022
City/Town of North Andover
System Pumping Record TOWN OF NORTH ANDOVEF�
r` 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:
1801 Turnpike St
Address
North Andover _ MA 01845
Citylrown State Zip Code
2. System Owner:
Direct Supply
Name
6767 North Industrial Road,
Address(if different from location)
Milwaukee WI 53223
Citylrown State Zip Code
8882257729 x
Telephone Number
B. Pumping Record
1. Date of Pumping 03/07/2022 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 No If yes, was it cleaned? ElYes No
5. Observed condition of component pumped:
Normal ato level Sin bottom sludge 5in top solids Path }waffles are intact
Main tine Cledz. No fitter is present on t1ire tdLiki cuzzent tank is not designed to
e used with a filter. over s secured. No 3rd party paperwork i e .
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
03/07/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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