HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1555 TURNPIKE STREET 7/18/2022 RECsrIVE�
Commonwealth of Massachusetts $2022
City/Town of North Andover �0 vER
System Pumping Record - wN OF rO 'H cME"j
y `TµpEpAF�
Form 4 HeA
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:
1555 Turnpike Street,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Debbie Limas
Name
1555 Turnpike Street,
Address(if different from location)
North Andover _ MA 01845
City/Town State Zip Code
9783170770 x
Telephone Number
B. Pumping Record
1. Date of Pumping 06/09/2022 _ 2 Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes FJVJ No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
sl'stem Operating Eine Normal- I-later le'rel— Moderate top solids M-daate hottom
current tan is not designed to be used with a filter. Cover s secured. Remove
1500 gallons. Recommended Boost additive,Wind River Septic System Treatment
additive.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
06/09/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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