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HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 99 PHEASANT BROOK ROAD 4/19/2022 IFtecelvec Commonwealth of Massachusetts City/Town of QpR 11 g 2022 Y North Andover System Pumping Record �owNOF�osPA VWOO FFMJ ^M DEP has provided this form for use by local Boards of Health.Other forms may be used,but the infor*ion 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: 99 Pheasant Brooke Road Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Rod Ballon Name 99 Pheasant Brooke Road, Address(if different from location) North Andover MA 01845 City/Town State Zip Code 5083148344 x Telephone Number B. Pumping Record 1. Date of Pumping 11/08/2021 2. Quantity Pumped. 1500.0000 Date Gallons 3. Component: ❑ Cesspool(s) © Septic Tank ❑Tight Tank ❑Grease Trap Other(describe): 4. Effluent Tee Filter present? F Yes © No If yes, was it cleaned? ❑Yes No 5. Observed condition of component pumped: sy^tem operating Pipen, ai ter > > Moderate tnp solids Heave bottom — 50th b.Lff2:t!,j d.Lt: ifltdUt. Main line etedr. Nu filter is present on the tank, current tank is not designed to be used with a filter. Cover s secured. Pumped 1500gallons. Recommended No Recommendation. 6. System Pumped By: Marcus Lark Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835 I." _ 11/08/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1