HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 58 PHEASANT BROOK ROAD 5/3/2023 RECEIVED
Commonwealth of Massachusetts
z City/Town Of North Andover MAY
System Pumping Record
Form 4 TOWN OF NLTH tOEP HLNT P
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DEP has provided this form for use by local Boards of Health.Other forms may be used,but the in ormation 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:
58 Pheasant Brook Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
John McCormick
Name
58 Pheasant Brook Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787712454
Telephone Number
B. Pumping Record
04/14/2023 1500.0000
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) FX-] Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes D No If yes, was it cleaned? 0 Yes No
5. Observed condition of component pumped:
System Operating Fine. Normal water level. Moderate top solids. Moderate bottom
sludge. Both baffles are intact. Main line Clear. Filter is present and has been
cleaned as needed. Cover(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:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
04/14/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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