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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 729 BOXFORD STREET 4/19/2022 'i�ecyjeu Commonwealth of Massachusetts 19V11 City/Town of North Andover APR ANDO\IEpI System Pumping Record FNoa�H ANT DE aTM Form 4 '• 4H o N v PA 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: 729 Boxford Street Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Jeff Simmons Name 729 Boxford Street, Address(if different from location) North Andover MA 01845 Citylrown State Zip Code 9786821784 x Telephone Number B. Pumping Record 1. Date of Pumping 11/17/2021 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? ❑Yes ❑ No 5. Observed condition of component pumped: System Operating Fine Nnrmal water level Tight i-np—gn1jdS Moderate bottom studge. Both bafftes dLe hitact. Main tine Clear. No fill—, p—mit an the tanki current tank is not designed to be used with a filter. Cover s secured. Pumped 1000 gallons. Recommended Boost additive,CCLS additive. 6. System Pumped By: Marcus Lark Nam Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA 11/17/2021 i 6ature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1