HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 336 SHARPNERS POND ROAD 10/18/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of North Andover OCT 18 2022
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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:
336 Sharpners Pond Road,
Address
North Andover MA 01845
Cityrrown State Zip Code
2. System Owner:
Ellen & Brian Fitzgerald
Name
336 Sharpners Pond Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
7812494950 x
Telephone Number
B. Pumping Record
1. Date of Pumping 09/16/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑X Yes No If yes, was it cleaned? Yes El No
5. Observed condition of component pumped:
System operating Fine- Normal water 12-21 I-Jght top salids- Maderate bottom
cleaned as needed. Cover(s) secure Remove ga ons. Recommen e Boost
additive,Wind River Septic System Treatment additive.
6. System Pumped By:
Robert Herrick
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
09/16/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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