HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 SUMMER STREET 4/19/2022 RECEIVED
�-L, Commonwealth of Massachusetts
City/Town Of North Andover APR 1 g 2022
a System Pumping Record
OF NORTH AN90VER
Form 4 TOWcN��T�{DEPARTMENT
M _ DEP has provided this form for use by local Boards of Health.Other forms may be used,but th�trrA911ion 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:
54 Summer Street
Address
North Andover MA 01845
Cityrrown State Zip Code
2. System Owner:
William& Barbara Ellard
Name
54 Summer Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
5082657736 xhouse
Telephone Number
B. Pumping Record
1. Date of Pumping 03/22/2022 _ 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) rjW-] Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? 0Yes ❑ No
5. Observed condition of component pumped:
System Operating Rine Normal are lava) Moderate top solids Moderate hattom
s±udge. Both buffies aze intact. Mciiii tine Ciear. No fi±tez is pze5ent an tile tanki
current tank is not designed to be used with a filter. Cover s secured. Remove
1500 gallons. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
_ 03/22/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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