HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 JERAD PLACE 12/12/2022 �1ECEIVE6
L, Commonwealth of Massachusetts
City/Town of North Andover TOWN OF NORTH ANDOVE
a System Pumping Record HEALTH f)ERARTMENI
r` 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:
25 Jerad Place,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Kathy & David Bardwell
Name
25 Jerad Place,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787297200 x
Telephone Number
B. Pumping Record
1. Date of Pumping 11/01/2022 2. Quantity Pumped: 2000.0000
Date Gallons
3. Component: ❑ Cesspool(s) Q Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑V No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
System Operating Fine- Normal- watgr moderate top sol-ids- Moderate bottom
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:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
11/01/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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