HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 790 FOREST STREET 7/6/2022 RECEIVED
Commonwealth of Massachusetts JUL 0 6 2022
} City/Town Of North Andover TOWN NORTH ANDOVER
HEALLTT H DEPARTMENT
_- System Pumping Record
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:
790 Forest Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Pam & Paul Guerrieo
Name
790 Forest Street,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786832404 x
Telephone Number
B. Pumping Record
1. Date of Pumping 04/22/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank ❑Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑X Yes No If yes,was it cleaned? N]Yes ❑ No
5. Observed condition of component pumped:
System ope;r-ating Eine- Normal- water lavel- Moderate top solids moderate bottom
sludge. Buth bafftes are intact. Main line Ctear. ftl:ter is pre5ent dnd lid5 been
cleaned as needed. 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:
HaverHill 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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