HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 BOSTON STREET 7/6/2022 RECEIVED
Commonwealth of Massachusetts
------- City/Town of North Andover JUL 0 6 2022
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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:
165 Boston Street,
Address
North Andover MA 01845
CitylTown State Zip Code
2. System Owner:
Eric Lynch
Name
165 Boston Street,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9788076348 x
Telephone Number
B. Pumping Record
1. Date of Pumping 04/22/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank ❑Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes FK-] No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System Operating Fil4e Normal water Moderate top solids Moderate bottom
current tank is not designed to b7e—used. with a tilter. Cover s secured.
Recommended Boost additive,CCLS additive.
6. System Pumped By:
Ronald Soucie
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Havv)e,,rHill Disposal Site: 40 s Porter St, Bradford, MA 01835
( 04/22/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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