HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 315 SOUTH BRADFORD STREET 1/25/2023 RECEIVED
Commonwealth of Massachusetts OAN 2 5 2023
City/Town of North Andover
System Pumping Record TOWN OF NORTH ANDOVER
y p g HEALTH DEPARTMENT
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:
315 South Bradford Street_
Address -
North Andover MA 01845
City/Town $fate_ -- — Zip Code
2. System Owner:
Michael Smolak Farms
Name
315 South Bradford,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9785002019 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? Yes 0 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
Normal--water-.-. leval_--3,iu--bottom_.s-l-udg€.--.-1-in--top-so 'i-cts-.--Roth-_baf.£]es-�.e...-
Main line: etectr. No fittez is present an tile tank, currant tank iS LlUt designed to
e used with a filter. over s secure . No 3rd party paperwork i e . Pumped
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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