HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 691 MIDDLETON STREET 10/3/2022 i
Commonwealth of Massachusetts pCT 0 32022
City/Town Of North Andover TOWN OFNORTHR M NT R
System Pumping Record H�,LTHCEPA
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:
695 Middleton Road, 695 Middleton Rd
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Commonwealth Dept. DCR Northeast Region
Name
25 Shattuck Street
Address(if different from location)
Lowell _ MA 01852
Cityrrown 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:
Narmal watar 4in bott., sludge 4in tQ solids Scth haffles are intact
Main line elear. No fitter ts pre5ellt Oil thF2 tdLiki current tcnik i5 L10t: designed to
e used with a filter. over s) secure . 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
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
RECENED
Commonwealth of Massachusetts 0C1 0 32022
City/Town of North Andover OF NORYN A��NT��
System Pumping Record roVAV15 °EPARTnn�
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:
698 Middleton Road
Address
North Andover MA 01845
City/Town 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: 5000.0000
Date Gallons
3. Component: El Cesspool(s) 0 Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
Normal water I-evel- 41J-p I�Qttom sludge 4in t-op solids Both baffles are 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
t5form4.doc•11/12 System Pumping Record•Page 1 of 1