HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 315 SOUTH BRADFORD STREET 7/13/2022 RECE1vEc
Commonwealth of Massachusetts F�C 1320�2
City/Town of North Andover �E Gq�rh/NORTN
R System Pumping Record oEpgRrMFNTE�
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:
315 South Bradford Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Michael Smolak Farms
Name
315 South Bradford,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9785002019 x
Telephone Number
B. Pumping Record
1. Date of Pumping 06/30/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes F No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
Normal Uxateri 3in bottom dg !-in top so-lids Both ]waffles are intactMain line Clear. No fitter is present oil tile tank; cu-crent: Lank is not clesigned to
e used with a filter. over s secured. No 3rd party paperwork i e .
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
06/30/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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