HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 781 FOREST STREET 7/6/2022 RECEIVED
� Commonwealth of Massachusetts JUL 0 6 2022
City/Town of Tcfti,N OF NORTH ANDOVER
North Andover HEALTH 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:
781 Forest Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
David Tao
Name
781 Forest Street,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9784904746 x
Telephone Number
B. Pumping Record
1. Date of Pumping 04/11/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) 0 Septic Tank ❑Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ]Yes ❑ No If yes, was it cleaned? Q Yes11 No
5. Observed condition of component pumped:
System Operating Fine Normal water I-evel— moderate top solids moderate hattom
cleaned as nee e . Cover s secured. 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:
163 Western Ave, Gloucester, MA 01930
04/11/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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