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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1072 JOHNSON STREET 4/19/2022 �EGE1VE� Commonwealth of Massachusetts R 192022 (_ City/Town of North Andover AP ANppVER System Pumping Record .�OwNOFt4oEPA lmoo Form 4 HEAtSHO M 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: 1072 Johnson Street, Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Linda Soucy Name 1072 Johnson Street, Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9789732953 x Telephone Number B. Pumping Record 1. Date of Pumping Date 11/02/2021 2. Quantity Pumped. Gaallonsllons 000 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 Pine N—wal wat-ex level- Moderat— top solirls Ddoderai-e batt-nM studge. Buth bafftes &�e intact. Main tine Ctecir. Nu fit— p—mit an the tailk, current tank is not designed to be used with a filter. Covers 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 11/02/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1