HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 FOREST STREET 1/25/2023 vjECEIVED
Commonwealth of Massachusetts
J AN 2 5 2W
11 City/Town Of North Andover V40TH OVEB
p System Pumping Record TpWNO1NpEppR MENT
Form 4
HEALTH
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:
75 Forest Street
Address
North Andover MA 01845
City/Town State--- -- .............. Zip Code _—_-----
2. System Owner:
Andrew Devore -
Name
75 Forest Street
Address(if different from location)
North Andover _ MA 01845
Cityfrown State Zip Code
6178940725
Telephone Number
B. Pumping Record
1. Date of Pumping 12/12/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank n Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes FX� No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
,System-Opesat i g Fine.. Normal- water-_l-eueL-_--Moderate--top-col-ids_--Mode rate-bottom---
,
current tank is not esigned to be used with a filter. Covers secured.
Recommended Boost additive,Wind River Septic System Treatment additive.
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:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
12/12/2022 _
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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