HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 MARIAN DRIVE 7/18/2022 RECENED
Commonwealth of Massachusetts JUG 18 Z022
--------
City/Town of North Andover jOW01
OF N0
R7H ANDOVER
m - System Pumping Record REAL H DEPARTMENT
A Form 4
be
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must substantially the same as that provided here.Before using this form,check with your local Board of Health to deterrmm
ine the form
rd of Health or other approving authority within 14
they use.The System Pumping Record must be submitted to the local Boa
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
35 Marian Drive,
Address
1845
North Andover MA 0 State �Code
Cityrrown
2. System Owner:
Nathan & Allison Ra
Name
35 Marian Drive
Address(if different from location)
1845
North Andover MA 0 State Zip Code
Citylrown
6034014803 x
Telephone Number
B. Pumping Record
06/14/2022 2 QuantityP 1500.0000
1. Date of Pumping Date Pumped: Gallons
3. Component: Cesspool(s) F)�( Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes,was it cleaned? 0 Yes No
5. Observed condition of component pumped: moderate top solids moderate bntx-om�
cleaned as needed. Covers secure Recommen e Boost a itive,Win River Septic
System Treatment additive.
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:
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
06/14/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1
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