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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 t5form4.doc•11/12 System Pumping Record•Page 1 of 1