HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1801 TURNPIKE STREET 7/7/2023 Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record v` pj1023
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:
1801 Turnpike Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Direct Supply
Name
6767 North Industrial Road
Address(if different from location)
Milwaukee WI 53223
City/Town State Zip Code
7042820530
Telephone Number
B. Pumping Record
1. Date of Pumping 06/21/2023 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:
Normal water level. lin bottom sludge. lin top solids. 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. No 3rd party paperwork filled.
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:
HaverHill Disposal Site: 40 S. Porter Street, Bradford, MA 01835
06/21/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
