HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 STONECLEAVE ROAD 7/6/2022 RECEIVED
<C�x Commonwealth of Massachusetts JUL 0 6 2022
City/Town of North Andover 'crWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
M 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:
37 Stonecleave Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Keith Graham
Name
37 Stonecleave Road,
Address(if different from location)
North Andover MA 01845
Citylrown State Zip Code
9782101746 x
Telephone Number
B. Pumping Record
1. Date of Pumping 05/19/2022 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 ❑X No If yes, was it cleaned? 11Yes ❑ No
5. Observed condition of component pumped:
System t g Fine Normal trader level Modem* top —lids moderate bottom
,
current tank is not designed to be used with a filter. Covers secured. Pumped
1000 gallons. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Marcus Lark
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed,
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
05/19/2022
ignat re-of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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