HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 456 SALEM STREET 10/10/2023 Commonwealth of Massachusetts
F City/Town of North Andover C� 1�1p'L3
System Pumping Record p
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:
456 Salem Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Janelle Barrow
Name
456 Salem Street,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787294637 x
Telephone Number
B. Pumping Record
1. Date of Pumping 09/13/2023 2 Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) X Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes 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:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
09/13/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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