HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 99 PHEASANT BROOK ROAD 12/12/2022 NECEtVEU
Commonwealth of Massachusetts
( City/Town Of North Andover � gOVEE
System Pumping Record rC,\6"�
Form 4
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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:
99 Pheasant Brooke Road,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Rod Ballon
Name
99 Pheasant Brooke Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
5083148344 x
Telephone Number
B. Pumping Record
1. Date of Pumping 10/20/2022 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 ❑X No If yes,was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System Operating Fine N rural * Moderate top solids Moderate r ttbun
current tank is not designed to be used with a filter. Cover s secured.
Recommended Boost additive,Wind River Septic System Treatment additive.
6. System Pumped By:
Michael Graham
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
--_ 10/20/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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