HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 SHERWOOD DRIVE 7/6/2022 RECEIVED
Se
Commonwealth of Massachusetts JUL 0 6 2022
City/Town of North Andover
System Pumping Record TOWN OF NORTH THEAND TER
Y p 9 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:
55 Sherwood Drive,
Address
North Andover MA 01845
Cityrrown State Zip Code
2. System Owner:
Ezzi Abou
Name
55 Sherwood Drive,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
5088013050 x
Telephone Number
B. Pumping Record
1. Date of Pumping 05/17/2022 2 Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) a Septic Tank ❑Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? M Yes 0 No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
System Operating Pine Normal- wata, 10"Q] pdoderate top gaj-j-ds Moderate bottom
current tank is not designed to be used with a filter. Cover s secured.
Recommended Boost additive,CCLS additive,Installing a riser.
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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