HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 STONECLEAVE ROAD 6/5/2023 Commonwealth of Massachusetts H�p,LTN
City/Town of North Andover �N 05 2�Z3
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:
37 Stonecleave Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Keith Graham
Name
37 Stonecleave Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9782101746 x
Telephone Number
B. Pumping Record
1. Date of Pumping 05/24/2023 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes FX—] No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System Operating Fine. Normal water level. Light 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:
South essex sewerage district: 50 Fort Ave, Po Box 989, Salem MA 01970
05/24/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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