HomeMy WebLinkAboutSeptic Pumping Slip - 162 Sutton St - Upper Crust - 10/02/2024 - Septic Pumping Slip - 162 SUTTON STREET 10/2/2024 Commonwealth mJMassachusetts
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North Andover
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 within14
days from the pumping date in accordance with 310CMR1n.us1.
A. Facility Information
1. System Location:
162 Sutton
Address
North Andover MA 01845
-6—ty/Town State ZiD Code
2. System Owner:
The. Crust
Name
286 Harvard Street
location—)—
Brookline MA 02446
cuyrrown State Zip Code
7572772967
Telephone Number
B. Pumping Record
lU 0.0000
1. Dat�ofPumping Date Gallons
Quantity G�nonu
3. Component F—lcesspool(s) R Septic Tank [—1 Tight Tank [��Grease Trap
[—1 Other(describe):
4. Effluent Tee Filter present? [—]Yes �� No U yes,was dcleaned? F-]Yes [—| No
5. Observed condition of component pumped:
no access
G. System Pumped By:
Raymond 3ae
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite I000 Marlborough, mm 01752
Company
7. Location where contents were disposed:
I0/02/2O24
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Signature cv Receiving Facility(or attach facility receipt) Date
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