HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 336 SHARPNERS POND ROAD 1/8/2024 Commonwealth of Massachusetts
_ City/Town of North Andover aN ti4
System Pumping Record
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:
336 Sharpners Pond Road,
Address ------
North Andover MA 01845
City/Town State Zia Code
2. System Owner:
Ellen & Brian Fitzgerald
Name
336 Sharpners Pond Road,
Address(if different from location)
North Andover MA 01845
Cityrrown State Zip Code
7812494950 x
Telephone Number
B. Pumping Record
1. Date of Pumping 08/16/2023 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 No If yes, was it cleaned? ❑X 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. Filter is present and has been
cleaned as needed. 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:
Gloucester WPCF: 50 Essex Avenue, Gloucester, MA 01930
08/16/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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