HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 240 OLD CART WAY 7/6/2022 RECEIVED
Commonwealth of Massachusetts JUL 0 6 2022
City/Town of North Andover
= System Pumping Record N OF NORTH ANIDOVER
Y p 9 HEALTH 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:
240 Old Cart Way
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Paul Harty
Name
240 Old Cart Way
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787941106
Telephone Number
B. Pumping Record
1. Date of Pumping 05/06/2022 2. Quantity Pumped: 2000.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank ❑Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes 0 No
5. Observed condition of component pumped:
System Operating Fine n� Nar at elm i Heavy elide. Moderate bnttom
studye. Euth bafftes axe intaut. Main line Clear. No filter is pxesent on ttle tank;
current tank is not designed to be usecl. with a filter. Cover s secured. Pumped
2000 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:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
05/06/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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