HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 305 MIDDLETON STREET 10/3/2022 �ECEIVE�°
Commonwealth of Massachusetts p�Z 32022
City/Town of North Andover AtypOVEii
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System Pumping Record TowNOFVA NOEPA�MENT
Form 4 HEp'Lf
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:
305 Middleton Road _
Address
North Andover _ MA 01845
Citylrown State Zip Code
2. System Owner:
Commonwealth Dept. DCR Northeast Region
Name
25 Shattuck Street
Address(if different from location)
Lowell _ MA 01852
City/Town State Zip Code
9789372092
Telephone Number
B. Pumping Record
1. Date of Pumping 07/28/2022 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? ❑Yes No
5. Observed condition of component pumped:
N cnrma l water l 1 9'n bottom_sludge lin top Sol I cis.—RGt h baffles intact
e used with a filter. Cover(s) secured. No 3rd party paperwork i e .
6. System Pumped By:
Michael Graham
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
07/28/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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