HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 660 SHARPNERS POND ROAD 10/3/2022 'ae'Vjev
Commonwealth of Massachusetts
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City/Town of North Andover p 3�021
System Pumping Record 0 No��N '"°y N�
Form 4 jo\0 HDrPP5
< M DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information `�rl
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:
660 Sharpeners Pond Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Jacquie Kane
Name
660Sharpeners Pond Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787647840 x
Telephone Number
B. Pumping Record
1. Date of Pumping 08/26/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank Tight Tank ❑Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes N] No If yes, was it cleaned? 11Yes ❑ No
5. Observed condition of component pumped:
System operating Wine� Normal to i of Light tap—se]ids Modexata bottom
tank;sluCiye. Buth bufftes are intact. Main line etear. Na filter is prestent Un the
current tan is not designed to be used with a filter. Cover s secured. Remove
1500 gallons. Please send one case of windriver additive. 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
08/26/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
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