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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 ACADEMY ROAD 4/19/2022 Commonwealth of Massachusetts R 91022 (_ City/Town of North Andover System Pumping Record Form 4 0�4A�SH p 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: 83 Academy Road Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Kathy Stevens _ Name 83 Academy Road, Address(if different from location) North Andover MA 01845 Citylrown State Zip Code 9786835522 x Telephone Number B. Pumping Record 1. Date of Pumping 11/17/2021 2. Quantity Pumped. 2000.0000 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 Nn l at l el MnAerate tnp QnliHg Moderate hot-tom current tank is not designed to be used with a filter. Cover s secured. Pumped 2000 gallons. Recommended Boost additive,CCLS additive. 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: Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA 11/17/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1