HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 224 SUMMER STREET 12/12/2022 RECEIVED
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City/Town Of North Andover TOW OF rw9ff1-H AAIgOVEkH&&THDEPAWMW
System Pumping Record
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:
224 Summer Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Pam & Chris Stad
Name
224 Summer Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9782588887
Telephone Number
B. Pumping Record
1. Date of Pumping 11/04/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) FK� 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:
sludge. Both bdffTe5 �ire intaut. Main tine Clear. No fill—I IS 13—Mit U11 the System Operating Fine Normal water level- Light top solids Maderate hoi-tom
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:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
11/04/2022
Si nature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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