HomeMy WebLinkAboutSeptic Pumping Slip - 1773 Salem �tet`dct � i tau",091e�«I
Commonwealth of Massachusetts
City/Town Of North Andover NOV 2 6 2024
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:
1773 Salem Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
James Henry
Name
1773 Salem Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9782893017
Telephone Number
B. Pumping Record
09/25/2024 1000.0000
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Component: Cesspool(s) 0 Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes No If yes,was it cleaned? Yes 0 No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Septic system serviced. Filter not
present. Tank cannot be outfitted with filter. 1000 gallons removed. Light sludge
on bottom of tank. Light top solids in tank. System is at proper working level.
Both baffles/tees are intact. Main line is clear. Customer purchased a pre-paid
repair item.
6. System Pumped By:
Jonathon Colson
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
Jonathon Colson 09/25/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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