HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1265 SALEM STREET 2/10/2023 RECEIVED
Commonwealth of Massachusetts FEe 1 �M-3
City/Town of North Andover -1-H ANDOVER
OF NOR
System Pumping Record TOME oTHDE.PARTMENT
Form 4
`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:
1265 Salem Street,
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Allison Halleck
Name
1265 Salem Street,
Address(if different from location)
North Andover MA 01845
Cityrrown State Zip Code
6172339903 x
Telephone Number
B. Pumping Record
1. Date of Pumping 01/09/2023 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank ❑Tight Tank ❑Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes rX—] No If yes,was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
Sys Operatinglne Normal water 1-el Moderate ton ,Sol-ids Moderate bottom
sludge. Butli baffies art! intact. Main lizie Cittar. Nu fitter iz:i present an ttie i
current tank is not designed to be used with a filter. over s 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:
NENO Yard: 163 Western Ave, Gloucester, MA 01930
01/09/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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