HomeMy WebLinkAbout- Septic Pumping Slip - 183 FOREST STREET 12/12/2022 RECEIVED
Commonwealth of Massachusetts
it City/Town Of North Andover
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:
183 Forest Street
Address
North Andover MA 01845
City[Town State Zip Code
2. System Owner:
Dennis & Susan Holland
Name
183 Forest Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786861681
Telephone Number
B. Pumping Record
1. Date of Pumping 11/11/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) FX� Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? ❑X Yes ❑ No
5. Observed condition of component pumped:
System Operating Fj=14e N a water levees Macterat e top—solids moderate hottom
cleaned as needed. Cover(s) secured. Pumped 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
11/11/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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