HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1801 TURNPIKE STREET 1/25/2023 Commonwealth of Massachusetts VJF oveo
(4 City/Town of North Andover
System Pumping Record
Form 4 RTH A400\JF
DEP has provided this form for use by local Boards of Health.Other forms may be used,but th���fTMEN
substantially the same as that provided here.Before using this form,check with your local Boar6M.- O't316 ,ermine 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:
1801 Turnpike St -
Address
North Andover MA 01845
City/Town Mate --- Zip Code -- ----
2. System Owner:
_ Direct Suit'— ------ - ------- -- ----
Name - ---�--- —
6767 North Industrial Road,
Address(if different from location)
Milwaukee WI 53223
Citylrown State Zip Code
8882257729 x
Telephone Number
B. Pumping Record
1. Date of Pumping 12/08/2022 __ 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) 0 Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? M Yes 0 No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
Norma I wa te,1:-..,level- 4-l.n hot t om -s-- - 2 J n--top-_so-1 i d s• Bo t h ha f f 1 c s 3-r-g--j n t act-----
e used with a tilter. over s secured. No 3rd party paperwork i e . Pumpe
gallons.
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:
163 Western Ave, Gloucester, MA 01930
/' 12/08/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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