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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1187 SALEM STREET 4/19/2022 Commonwealth of Massachusetts (u _ City/Town Of North Andover 1 g 2022 a - a System Pumping Record APR �+oov�t Form 4 WN OF n�pAa�;�rT DEP has provided this form for use by local Boards of Health.Other forms may be used,but the�iQ�p�(fpFttlsTbe substantially the same as that provided here.Before using this form,check with your local Board off 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: 1187 Salem Street Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Donna Hurlburt Name 1187 Salem Street Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9788570678 Telephone Number B. Pumping Record 1. Date of Pumping 11/11/2021 2. Quantity Pumped: 1500.0000 Date Gallons 3. Component: Ej Cesspool(s) © Septic Tank F1 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: SN—tnm aperatin7 Fin Nn al uatar lcvcl Mnr9ordt0 tA� SOliGtS Moderate bottom current tank is not designed to be used with a i ter. 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: 163 Western Ave, Gloucester, MA 01930 11/11/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1