HomeMy WebLinkAboutSeptic Pumping Slip - Septic Pumping Slip - 271 CANDLESTICK ROAD 9/27/2024 i
Commonwealth of Massachusetts
Clty/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
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:
271 Candlestick Road
Address
North Andover MA 01845
CityfTown State Zip Code
2. System Owner:
Keith l,aezza
Name
271 Candlestick Road
Address(if different from location)
North Andover MA 01845
CitylTown State Zip Code
9783975200
Telephone Number
B. Pumping Record
09/27/2024 1000.0000
1, Date of Pumping bate 2. Quantity Pumped: Gallons
3. Component: ❑Cesspool(s) Septic Tank ❑ Tight lank ❑Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes Z No If yes, was it cleaned? Yes 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. Fight~ sludge
on bottom of tank. Tight top solids in tank. System is at proper working level.
Both baffles/toes 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:
NENO Yard: 163 Western Ave, Gloucester, MA 01930
Jonathon Colson 09/27/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 or 1