HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 SUNSET ROCK ROAD 7/18/2022 BECENED
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record ,�,,.THANpON
Form 4 ;�v% ,M"ENT
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:
66 Sunset Rock Road,
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Steve Mouzakis
Name
66 Sunset Rock Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9782732482 x
Telephone Number
B. Pumping Record
1. Date of Pumping 06/29/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? D Yes No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System operating Fine- Normal water mndogratG top solids modGrate bottom
5turdye. Both baffles axe intact. Matn ttim elear. Nu fitter is present: on t:he! tank;
current tank is not designed to be used with a filter. Cover s secured. Customers
driveways new asphalt he request that nobody ever Park on it please pump in the
street three hoses to do the job also bring tarp with you customer works very hard
on his grass he's requesting that we always use a tarp please dig as neatly as
;hlo V—i, ,A-ri Anncf onr7i*;.m rn1;nA A;.>cr Cenf-in Cvetcm Trcotmcnt �riAifivo
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:
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
06/29/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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