HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 183 FOREST STREET 8/5/2024 A,�do�et
Commonwealth of Massachusetts \NT\
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.Other forms maybe used,but the information must be ^^. r
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:
183 Forest Street
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Dennis & Susan Holland
Name
183 Forest Street
Address(if different from location)
North Andover MA 01845
Cityfrown State Zip Code
9786861681
Telephone Number
B. Pumping Record
07/17/2024 1500.0000
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Component: El Cesspool(s) Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑X Yes ❑ No If yes, was it cleaned? ❑X Yes No
5. Observed condition of component pumped:
System not Operating Fine. High 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.
6. System Pumped By:
Marcus Lark
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Ipswich WWTP: 21 Fowlers Lane, Ipswich , MA 01938
Marcus Lark 07/17/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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