HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1483 SALEM STREET 10/18/2022 RECEIVED
OCT 18 2022
Commonwealth of Massachusetts TOWN OF NORTH ANDOVER
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City/Town of North Andover HEALTH DEPARTMENT
System Pumping 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:
1483 Salem Street,
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Hope Ralph
Name
1483 Salem Street,
Address(if different from location)
North Andover MA 01845
CitylTown State Zip Code
7814249679 x
Telephone Number
B. Pumping Record
1. Date of Pumping 09/06/2022 2. Quantity Pumped: 2500.0000
Date Gallons
3. Component: ❑ Cesspool(s) FK� Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes ❑X No If yes,was it cleaned? ❑Yes No
5. Observed condition of component pumped:
System not Operating E-ne High 14a Qr level H-avy top solic]2 Mcderat- hottnm
current tan is not esigne to e use wit a >. ter. Cover s secure System
Evaluation recommended . Repairs needed: System not working both the pump chamber
and septic tank were both over filled about the spill over into the yard floats
look like they're not working correctly. You can pull directly into this driveway
'+ r,ll +hrnh n-ch o.,o 4f ,.nn o lnr.binn +r�r +hc r,nmr. rah�mhor 4+ ,c +n +ho
6. System nn Pumped By:
Ronnie Soucie III
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
T<' 09/06/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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