HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 34 BOXFORD STREET 7/6/2022 RECEIVED
JUL 0 6 2022
Commonwealth of Massachusetts
City/Town of TOWN 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:
34 Boxford Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Jim Savarino
Name
34 Boxford Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9788284129
Telephone Number
B. Pumping Record
1. Date of Pumping 05/10/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) Q 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 Fine Normal- water Moderate tQP solids Moderate bottom
current tank is not designed to be used with a filter. Cover s secured. System is
operating okay. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Ron Soucie
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
05/10/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1