HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 143 LACY STREET 10/3/2022 AE'Swev
<CN Commonwealth of Massachusetts 3202Z
City/Town Of North Andover
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System Pumping Record FNo EN
Form 4 TO Hip,vN pEpARSM
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:
143 Lacy Street,
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Steph O'Mahony,
Name
143 Lacy Street,
Address(if different from location)
North Andover MA 01845
Cityrrown State Zip Code
6175937917 x
Telephone Number
B. Pumping Record
1. Date of Pumping 07/29/2022 _ 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) 0 Septic Tank ❑Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? N]Yes ❑ No If yes, was it cleaned? ❑X Yes No
5. Observed condition of component pumped:
System operating Fine Normal water J-ejTel-- MaHerate tQp solids Moderate battom
cleaned as needed. Cover s secured. Removed 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
07/29/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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