HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1773 SALEM STREET 7/18/2022 aECE1VETD
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Commonwealth of Massachusetts 1 S 2022
City/Town of North Andover J0-
System Pumping Record w�c�N°RcriR M NTa
Form 4 30 �SN DFp�'
M 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:
1773 Salem Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
James Henry
Name
1773 Salem Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787755477
Telephone Number
B. Pumping Record
1. Date of Pumping 06/07/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) X❑ Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 11Yes X No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
System Operating Fine Normal- water Moderate top SQ'ids made'ate bottom,
current tank is not designed to be useci with a filter. Cover s secured. Remove
1000 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:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
06/07/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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