HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 WINDKIST FARM ROAD 8/29/2024 ICN Commonwealth of Massachusetts
Clty/Town of North Andover
w° System Pumping Record
Form 4 ®� 001`b� eC °
DEP has provided this form for use by local Boards of Health. Other forms may be used, but�t
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,purmping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 125 Windkist Farm Road
use only the tab
key to move your Address
cursor-do not North Andover MA 01845
use the return City/Town State Zip Code
key.
A`� 2. System Owner:
Windkist Equestrian Center
Name
seam
Address(if different from location)
Cityrrown State Zip Code
978-688-7662
Telephone Number
B. Pumping Record
1. Date of Pumping Date 7.12.24 2. Quantity Pumped: 1000
Gallons
3. Component: ❑ Cesspool(s) ® 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:
6. System Pumped By:
Fernando Costa
Name Vehicle License Number
Service Pumping & Drain Co., Inc.
Company
7. Location where contents were disposed:
GLSD
7.12.24
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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