HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2211 SALEM STREET 12/12/2022 DECEIVED
Commonwealth of Massachusetts
City/Town of North Andover TOw�(1F�vTAF�TMDENT
System Pumping Record �EA��a,vEP
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:
2211 Salem Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Mary Coughlan
Name
2211 Salem Street
Address(if different from location)
North Andover MA 01845
Citylrown State Zip Code
9786837276
Telephone Number
B. Pumping Record
1. Date of Pumping 10/17/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Q Septic Tank ❑Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes F)C] No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
System Operating Fine Normal watar lc c1 Heavy to solids Light bottom sludge
tank is not designed to be used with a filter. Cover s secured. To gain access to
this property the driveway is sharpeners Pond Road it is a shared driveway number
400 name on the mailbox will be BECK it is the last house on the driveway also be
careful when entering the driveway electrical wires go across the front of the
'4'4--." thcv an 1-,., Kn;— — the lcPt h P chic of 1-hc r]r;vcv�v hcni nni nn - 1-h;c
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
t5form4.doc•11/12 System Pumping Record•Page 1 of 1