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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 143 PHEASANT BROOK ROAD 4/19/2022 i eecvvEU Commonwealth of Massachusetts 19 JW City/Town of North Andover APR oVER a _ o System Pumping Record SOwNOZNOEPAR MEND �c Form 4 NEAL 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: 143 Pheasant Brook Road Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Stephanie Lamarca Name 143 Pheasant Brook Road, Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9787380098 x Telephone Number B. Pumping Record 1. Date of Pumping Date 11/16/2021 2. Quantity Pumped. Gaallonsllons 000 3. Component: Cesspool(s) © Septic Tank ❑Tight Tank Ej 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 ope ar; g F; Nam,-Mal .gate, ueav>> tap selids Mederate bottom studge. Both bafftes ale intact. Mct±ii line etedr. No ftiter is present an thre tank, current tank is not designed to be used with a filter. Cover s secured. Pumped 1500gallons. Recommended Boost additive,CCLS additive. 6. System Pumped By: Marcus Lark Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste 4110, Hudson, MA 01749 Company 7. Location where contents were disposed.- Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA 'R'Yn 11/16/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1