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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 409 FOREST STREET 4/19/2022 iivecs eo Commonwealth of Massachusetts APR 19911 (_ City/Town Of ANo�ER System Pumping Record ;�"'�'OTHoSpA�M�NT - y Pumping HEA _ Form 4 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: 409 Forest Street, Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Claire King Name 409 Forest Street, Address(if different from location) North Andover MA 01845 Cityrrown State Zip Code 9786883615 x Telephone Number B. Pumping Record 1. Date of Pumping 11/03/2021 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: C7etem n eratin; Fine Normal nrater le-el Moderate top sellds Moderate bottom studge. Buth baffles cirre intact. Main tine e±ectr. No fill current tan is not designedto be used with a filter. over s secured. Recommended Boost additive,CCLS additive. 6. System Pumped By: Michael Graham 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 11/03/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1