HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 107 GRAY STREET 1/3/2024 Commonwealth of Massachusetts ,�"
City/Town of North Andover `'S1�
-_ - 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:
107 Gray Street
Address
North Andover MA 01845
CityFrown State Zip Code
2. System Owner:
Olga Rotaru
Name
107 Gray Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
8573739257
Telephone Number
B. Pumping Record
1. Date of Pumping 11/29/2023 2 Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? X Yes No If yes, was it cleaned? 0 Yes F1No
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 No Recommendation. Recommend
using boost next pumping. Adding treatment between now and then will improve the
health of your system. Please visit https://portal.wrenvironmental.com/ to
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:
NENO Yard: 163 Western Ave, Gloucester, MA 01930
Robert Herrick 11/29/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112 System Pumping Record•Page 1 of 1