HomeMy WebLinkAboutSeptic Pumping Slip - 83 Academy Rd - 10/8/24 - Septic Pumping Slip - 83 ACADEMY ROAD 10/8/2024 Commonwealth of Massachusetts
rA C' Dnf North Aodo,er
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 maccordance with a1ooMm15.351.
A. Facility Information
1. System Location:
83 Academy Road,
Address
North Andover MA 0I845
City/Town state ZIP code
2. System Owner:
�at�h Stevens
Name
83 Academy Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786835522 x
Telephone Number
B. Pump~ng Record
10/08/2024 2000.0000
1. Dateof�umping Date Gallons
Quantity Pumped: Ga|�nm'
3. Component: F—lCamopoo|(e) Septic Tank Tight Tank Grease Trap
| | 0thor(desnhbe):
4. Effluent Tee Filter present? [—1 Yes FX—] No |f yes, was iicleaned? [—]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. z000 9azzoon removed. Moderate
azoug* on bottom of tank. Moderate amount of tog solids in tank. System is at
proper working level.. Both baffles/tees are intact. Main line is clear.
G. System Pumped By:
Marcus Lark
Name Vehicle License Number
Wind Riveri izotte Drive, Suite
Company
7. Location where contents were disposed:
mEm0 Yard: 163 Wes-tern Ave, Gloucester, Ma 0I930
Maz000 Lark
lO/08/2O24
Signature ufHauler Date
Signature of Receiving Facility(or attach facility receipt) Date