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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 JERAD PLACE 4/19/2022 DECEIVED Commonwealth of Massachusetts APR 192022 VER �= City/Town of North Andover NO¢�H AN ENT W system Pumping Record �pH���HOEPAaj a 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: 25 Jerad Place Address MA 01845 North Andover State Tin Code City/Town 2. System Owner: Kathy & David Bardwell Name 25 Jerad Place Address(if different from location) MA 01845 North Andover State Zip Code City/Town 9786859004 x Telephone Number B. Pumping Record 11/03/2021 2 P 2000.0000 1. Date of Pumping Date Quantity Pumped: 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: ie current be use with cure . 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: 163 Western Ave, Gloucester, MA 01930 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