HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 74 WILLOW RIDGE ROAD 7/6/2022 RECEIVED
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Commonwealth of Massachusetts JUL 0 6 2022
City/Town of TOWN OF NORTH ANDOVER
North Andover I11EALTH 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:
74 Willow Ridge Road,
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Jason Rotchstein
Name
74 Willow Ridge Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
7816035712 x
Telephone Number
B. Pumping Record
1. Date of Pumping 04/19/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) [.-V� Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
System Operating Eine- Normal 1latgr Moderate top solids Moderate hattom
current tank is not designed to be used with a tilter. Cover s secured. Remove
1500 gallons. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Robert Herrick
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
04/19/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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