HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 255 FOREST STREET 10/18/2022 RECEIVED
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Commonwealth of Massachusetts OCT 18 2022
City/Town of North Andover
-- -_ � System Pumping Record TOWN OF NORTH ANDOVEF+.
y p 9 HEALTH DEPARTMENT
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:
255 Forest Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Elizabeth Wdow
Name
255 Forest Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786826418 xhome
Telephone Number
B. Pumping Record
1. Date of Pumping 09/21/2022 2. Quantity Pumped: Ga o0s 0000
Date
3. Component: ElCesspool(s) 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:
S�'StaN Operating Fine Normal watar I-Quel modeLate top solids Hea"Ir bottom
current tank is not designe to e use wit a i ter. Covers secure Pumpe
1000 gallons. Recommended No Recommendation.
6. System Pumped By:
Marcus Lark
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
09/21/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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