HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 63 CROSSBOW LANE 7/6/2022 RECEIVED
Commonwealth of Massachusetts JUL 0 6 2022
City/Town of Ncrth Andover
'"OWN 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:
63 Crossbow Lane
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Edith Duffy
Name
63 Crossbow Lane,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
5083359182 x
Telephone Number
B. Pumping Record
1. Date of Pumping 05/17/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) rjW-] Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? a Yes ❑ No
5. Observed condition of component pumped:
System Operating Fine- Narmal- I'latar D4nderate top Mndar,i-a bottom
beeir-
cleaned as needed. 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:
Gloucester WPCF: 50 Essex Avenue, Gloucester, MA 01930
05/17/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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