HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 160 CANDLESTICK ROAD 10/3/2022 Commonwealth of Massachusetts 0�� p 3 TV
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_- System Pumping Record �oHeA jHOEPA AMENS
Form 4
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:
160 Candlestick Road
Address
North Andover_ MA 01845
Citylrown State Zip Code
2. System Owner:
Elias (Lee) Salgado
Name
160 Candlestick Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9784074927 x
Telephone Number
B. Pumping Record
1. Date of Pumping 08/17/2022 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? Yes ❑X No If yes, was it cleaned? 0 Yes ❑ No
5. Observed condition of component pumped:
System opgrating Fine- Normal ulater leAral Mnderate top splids- Moderate hottom
current tan is not esigne to a use with a filter. Cover s secured.
Recommended Boost additive,Wind River Septic System Treatment additive.
6. System Pumped By:
Ronnie Soucie III
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
,c 08/17/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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