HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 21 FULLER MEADOW ROAD 12/12/2022 a�cE�vEo
Commonwealth of Massachusetts
City/Town of North Andover fH p,000vER
System Pumping Record sONNC)F EPART�'ENT
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:
21 Fuller Meadow Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Natalie Kissel
Name
21 Fuller Meadow Road
Address(if different from location)
North Andover MA 01845
Cityrrown State Zip Code
9786883125
Telephone Number
B. Pumping Record
1. Date of Pumping 10/17/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) FK� Septic Tank Tight Tank ❑Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes � No If yes,was it cleaned? Yes 0 No
5. Observed condition of component pumped:
system in 7ine N l Ylater 1 l Haa.vy tnn solic1c Imight bGttnm sludger_
Buth bdff±e5 dre intact. Main tine e±eir. No fitter is prtz!sent on tile tanki carrent
tank is not designed to be used with a filter. Cover(s) secured. Approximately 24
inches of top solids and about eight inches of sludge on the bottom tank and
benefit from a boost combination customer denied bacteria. Recommended Boost
additive,Wind River Septic System Treatment additive.
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
10/17/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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