HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 107 GRAY STREET 12/12/2022 RECEIVED
Commonwealth of Massachusetts
City/Town Of North Andover
a System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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:
107 Gray Street,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Olga Rotaru
Name
107 Gray Street,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
8573739257 x
Telephone Number
B. Pumping Record
1. Date of Pumping 11/30/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank R Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑X Yes ❑ No If yes, was it cleaned? ]Yes ❑ No
5. Observed condition of component pumped:
System Operating Fine- Normal water I-evel- mQderate tQp 2C]JcI2 modgrate bottom
cleaned as needed. Cover(s) secured. ??. Recommended Boost-a-d-U-Hive,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
11/30/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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