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HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 111 CAMPBELL ROAD 12/12/2022 �AECVIW Commonwealth of Massachusetts City/Town of North Andover r yr NO�PA�M,vN� System Pumping Record kAIE H 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: 111 Campbell Road Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Caroline Buchta Name 111 Campbell Road, Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9787646789 x Telephone Number B. Pumping Record 1. Date of Pumping 10/05/2022 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? Yes No If yes, was it cleaned? Yes ❑ No 5. Observed condition of component pumped: System Operating Fine- Normal watar 1-avel Moderate top Solids Moderate bottom 3ludge. Both bdfftes cize intact. Main line Ctear. No fitter ..Ls presmit U11 the tdl current tank can be outfitted with a filter. over s secured. System Evaluation recommended . Repairs negded: Outlet cover is crumbling apart 25% of the cover is gone also tank wall directly above the outlet is crumbling apart spoke with maintenance technician Tim system is operating fine but he States the tank needs to 1— —1—A T nl...I-A r.n1-,. ,n rho ,.,nrY "A., 'r-1, 'c q. to he ,- I.—I 6. System 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: Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA k'"% 10/05/2022 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1