HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 216 FOSTER STREET 12/12/2022 �ECEIVEv
Commonwealth of Massachusetts
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City/Town of North Andover IOWNOT ORTH N �
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System Pumping Record
Form 4
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:
216 Foster Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Marie S_prow
Name
216 Foster Street
Address(if different from location)
North Andover_ MA 01845
City/Town State Zip Code
9788871162
Telephone Number
B. Pumping Record
1. Date of Pumping 11/03/2022 _ 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank ❑Tight Tank ❑Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes � No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System Operating Eing Normal water moderate top solids Moderate bottom
sludge. Buth baffles zize iiitaut. Main line elear. No filter is preserit: an the tanki
current tan is not EFesigned 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:
163 Western Ave, Gloucester, MA 01930
11/03/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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