HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1216 SALEM STREET 12/12/2022 RECEIVED
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Commonwealth of Massachusetts
City/Town of North Andover L�l�
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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:
1216 Salem Street,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Carl Gustenhoven
Name
1216 Salem Street,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787784695 x
Telephone Number
B. Pumping Record
1. Date of Pumping 11/04/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes a No If yes, was it cleaned? Yes 0 No
5. Observed condition of component pumped:
System Operating Fine- Normal water i e'Te Tight top solids ModQrate hottom
tank; current tank is not designed to be used with a filter. Cover(s) secured.
Recommended Outlet Tee.
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
Ix 11/04/2022
Sic
ghature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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