HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 TURNPIKE STREET 10/18/2022 RECENED
Commonwealth of Massachusetts ocT 18 2022
City/Town Of North Andover
m y 9 HEALTH DEPARTMENT
a _ � System Pumping in Record
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:
1801 Turnpike St
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Direct Supply
Name
6767 North Industrial Road,
Address(if different from location)
Milwaukee WI 53223
City/Town State Zip Code
8882257729
Telephone Number
B. Pumping Record
1. Date of Pumping 09/29/2022 1000.0000
p g Date 2. Quantity Pumped:
Gallons
3. Component: El Cesspooi(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes FJW� No If yes,was it cleaned? Yes R No
5. Observed condition of component pumped:
Normal water le-val di-n hottom s1A,dge 2in tGp solids B-th bafflas are intact-
e used wit a i ter. Cover(s) secure No r party paperwor 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:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
09/29/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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