HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 PENNI LANE 3/6/2023 Commonwealth of Massachusetts
City/Town of North Andover F� 0 `0o0\01
System Pumping Record M 0i MtiN,
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:
102 Penni Lane,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Ana-Puala Fernandes
Name
102 Penni Lane,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6507430142 x
Telephone Number
B. Pumping Record
1. Date of Pumping 02/01/2023 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X 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:
qltem operating Pine Normal_ wate, 1—Tal Moderate top solids bdvAerate h'ttom
sludge. Buth bufftes are intact. Main line elecir. No fiiter is present on the tanki
current tank can be outfitted with a filter. over s secured. Tankis located in
the front of the house to the right hand side front yard two heavy duty cast iron
caps on the surface tank is one chamber 1,500 gallons removed top solids 10 in
bottom sludge almost non-existent three hoses required to complete this job from
t1— „ '1- „co ,a.;..c..,o.. ncr ,-cn„ect of n„c�nmcr fi l to ,c .,,-coc„r m�.,L
6. System Pumped By:
Ronnie Soucie III
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
i
j 02/01/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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