HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 274 OLD CART WAY 7/18/2022 R 051'so
Commonwealth of Massachusetts ,v- 1 g 2022
City/Town of North Andover N pao AND NJ.f
System Pumping Record TON�oWosvAR�M�N
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:
274 Old Cart Wav
Address
MA 01845
North Andover State Zia Code
City/Town
2. System Owner:
Ellen Palumbo
Name
274 Old Cart Way,
Address(K different from location)
MA 01845
North Andover — State Zip Code
City/Town
9783616256 x
Telephone Number
B. Pumping Record
06/21/2022 1500.0000
Date
1. Date of Pumping 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) 0 Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes F)-(] No If yes,was it cleaned? El Yes No
5. Observed condition of component pumped:
solids ma
stu
current E:ajjjE is not esigne to e use wit a i ter. Cover s) secure .
Recommended Boost additive,Wind River Septic System Treatment additive.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
rive, Suite 1000, Marlborough, MA 01752
Wind River Environmental, 46 Lizotte D
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District 240 Charles Street North Andover, MA
06/21/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
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