HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 50 HAY MEADOW ROAD 10/18/2022 RECEIVED
Commonwealth of Massachusetts OCT 18 2022
City/Town of North Andover
TOWN OF NORTH ANDOVER
System Pumping Record 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:
50 Hay Meadow Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Jessica Kirk
Name
50 Hay Meadow Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787350875
Telephone Number
B. Pumping Record
1. Date of Pumping 09/12/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank ❑Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 11Yes FX-] No If yes,was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System OperatingRine Normal waterof Heavytop salic]2Moderate battom
current tank is not esigne to e used with a filter. Cover-Ts). secured. Remove
1500 gallons. Recommended 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:
Gloucester WPCF: 50 Essex Avenue, Gloucester, MA 01930
09/12/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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