HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 122 BOXFORD STREET 10/3/2022 RECE�vEc I'
3 20�Z
Commonwealth of Massachusetts
City/Town of North Andover NOFt1°�pA MEND
System Pumping Record HEN-'"°
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:
122 Boxford Street,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Patty Chesebrouah
Name
122 Boxford Street,
Address(if different from location)
North Andover MA 01845
Citylrown State Zip Code
6175497735 x
Telephone Number
B. Pumping Record
1. Date of Pumping 07/19/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) rK-] Septic Tank ❑Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
Iola water le"ej Light tGP solids maderate bGttom 51�ldge- Roth haffles a'G intact
e used with a filter. Cover s secured. 1000x pumped. Recommended No
Recommendation.
6. System Pumped By:
Barlendy Santos
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
07/19/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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