HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 JERAD PLACE 7/6/2022 RECEIVED
Commonwealth of Massachusetts JUL 0 6 2022
City/Town of North Andover TC'r'N i.r Noi7,TN ANDOVER
System Pumping Record ;EALTH DEPARTMENT
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:
10 Jerad Place
Address
North Andover MA 01845
Cityrrown State Zip Code
2. System Owner:
Michael Levin
Name
10 Jerad Place,
Address(if different from location)
North Andover MA 01845
Cityrrown State Zip Code
6178385376 x
Telephone Number
B. Pumping Record
1. Date of Pumping 05/26/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) rK-] 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. High water leve, HeavI, top solids Light bottom sludge
tank can beo-u-t=-Hed with a filter. Cover(s) secured. Recommended Boost
additive,CCLS additive.
6. System Pumped By:
Ron Soucie III
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
'Z 05/26/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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