HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 ACADEMY ROAD 12/12/2022 'JECEIVEL'
Commonwealth of Massachusetts
City/Town of North Andover
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System Pumping Record row MENT
Mo�NOFk arsoo
Form 4 `-C4jL i bEPArR'T
M 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:
83 Academy Road,
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Kathy Stevens
Name
83 Academy Road,
Address(if different from location)
North Andover MA 01845
Cityrrown State Zip Code
9786835522 x _
Telephone Number
B. Pumping Record
1. Date of Pumping 10/26/2022 _ 2. Quantity Pumped: 2000.0000
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes R] No If yes,was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
System operating Fine Normal water Moderate top solids Moderate h t t m
studge. Buth bafftes dre intact. Main line CIecir. No fill— p—mit an the ,
current tan is not designed to be used with a filter. Cover s secured. Pumped
2000 gallons. Recommended No Recommendation.
6. System Pumped By:
Marcus Lark
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
10/26/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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