HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 650 FOREST STREET 10/3/2022 REGvvSp
Commonwealth of Massachusetts ��� `Z11 ova
City/Town Of North Andover OwNO�NOApPR MEN1
System Pumping Record 1 HEP�-1
r` 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:
650 Forest Street
Address
North Andover _ MA 01845
Citylrown State Zvi Code
2. System Owner:
Robert/Patricia Gohn
Name
650 Forest Street,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
5082659213 x
Telephone Number
B. Pumping Record
1. Date of Pumping 08/01/2022 _ 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 ❑X No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
cy,b operating Fine- Normal wata, el T • ,ht top solids Mpderata bottem
sludge. Buth baffles cue ijit:act. Main iine Ctea.L. No ftiter is present on t:he tank;
current tank 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:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
08/01/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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