HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 HAY MEADOW ROAD 7/7/2023 Commonwealth of Massachusetts
= 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:
50 Hay Meadow Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Jessica Kirk
Name
50 Hay Meadow Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787350875
Telephone Number
B. Pumping Record
1500.0
1. Date of Pumping Date 06/28/2023 Gaallonsllons 2 Quantity Pumped: 000
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes ❑X No If yes, was it cleaned? 0Yes ❑ No
5. Observed condition of component pumped:
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:
Michael Graham
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
06/28/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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