HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 305 ABBOTT STREET 1/25/2023 RECEIVED
Commonwealth of Massachusetts
------ JAN 2 5 2023
City/Town of North Andover
IR 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:
112 Abbott Street,
Address -
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Justin Monza
Name -
112 Abbott Street,
Address(if different from location)
North Andover - _ MA 01845 _
City/Town State Zip Code
8453925890 x _
Telephone Number
B. Pumping Record
1. Date of Pumping 12/19/2022 2 Quantity Pumped: 2500.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? M Yes ❑X No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
System ng -water level._Level----moderatte--top
--sal-a ds- Modgs_�te-laof tram--
,
current tank is not designed to be used with a filter. Cover s secured. Repairs
needed: Pump or float. Pumped 2500 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:
163 Western Ave, Gloucester, MA 01930
12/19/2022
Signature of Hauler Date
Si nature of Receiving Facility
(or attach facility receipt) Date
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