HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 TURNPIKE STREET 7/18/2022 V�S,SNSID
<C�x Commonwealth of Massachusetts 1 $2022
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City/Town of North Andover
o System Pumping Record c4 �;,act
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:
1801 Turnpike St _
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Direct Supply
Name
6767 North Industrial Road,
Address(if different from location)
Milwaukee WI 53223
City/Town State Zip Code
8882257729
Telephone Number
B. Pumping Record
1. Date of Pumping 06/10/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: El Cesspool(s) a Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes 0 No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
Normal atcr 1 1 4in battam Sludge 4-in toP--Solids Bath haf-fles arQ i-ntact
e used with a filter. Cover s secured. No 3rd party paperwork i e . Water level
normal baffles intact no filter present mainline clear light solids and sludge
pumped 1000 gallons of grease cover secured.
6. System Pumped By:
Geoffrey Howard
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780
06/10/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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