HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 314 REA STREET 7/6/2022 RECEIVED
Commonwealth of Massachusetts JUL 0 6 2022
City/Town of North Andover Y
pbVN OF NORTH ANDOVER
_ System Pumping Record HEALTH DEPARTMENT
Form 4
w 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:
314 Rea Street,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Amy Cianciaruso
Name
314 Rea Street,
Address(if different from location)
North Andover MA 01845
CitylTown State Zip Code
9789798301 x
Telephone Number
B. Pumping Record
1. Date of Pumping 04/14/2022 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? [—,V]Yes ❑ No If yes, was it cleaned? X❑Yes No
5. Observed condition of component pumped:
System OperatingPine- Normal uoaterlal-1 l nn d r ate tGp solids Maderata battom
cleaned as needed. Cover s secure . Recommended Boost additive,CCLS additive.
6. System Pumped By:
Michael Graham
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
=� 04/14/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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