HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 925 FOREST STREET 5/25/2023 EPP��M�N
Commonwealth of Massachusetts NtiP�-\N� 3
City/Town of North Andover
System Pumping Record
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:
925 Forest Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Simonne Dolfe
Name
925 Forest Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787949355
Telephone Number
B. Pumping Record
1. Date of Pumping 04/14/2023 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 ❑X No If yes, was it cleaned? 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. No filter is present on the
tank; current tank is not designed to be used with a filter. 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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