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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 305 MIDDLETON STREET 6/29/2026 Town of earth Andover L\ Commonwealth of Massachusetts City/Town Of North Andover JUL 22 System Pumping Record Farm 4 Healtil Department X D P 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 CIMIR 15.351. A. Facility Information 1. System Location: 698 Middleton Road dre Adss.--..._.. _ North Andover_..__ MA 01845 City/Town 2. System Owner: Commonwealth.. Dept.�DCR Northeast _Recri°n:._...�`.__Berry Pond -_Harold Parker State Name 25 Shattuck Street Address('rf different from location) Lowell ._._._._._ MA _._._ _� 01852 __-- City/Town State Zip Code 9784657223 Telephone Number B. Pumping Record 06/29/2026 2500.0000 1. Date of Pumping ._�...___..__.. __.__-_.- 2. Quantity Pumped: ---._....___....._.__.__�_..�.._..._.___ Date Gallons 3. Component: © Cesspool(s) FX-]Septic Tank ®Tight Tank ®Grease Trap Other(describe): 4. Effluent Tee Filter present? ®Yes FX] No If yes, was it cleaned? ®Yes R No 5. Observed condition of component pumped: Septic system serviced. Filter not present. Tank can be outfitted with filter - Sold onsi.te. 2500 gallons removed. 3 .inches of bottom sludge. 3 inches of top solids. System is at proper working level. Both baffles/tees are intact. Main line is clear. 6. System Pumped By: Sergio Polanco .._.__. __ __-- _.._.___....._..._ ....._..._.-- ----._.._.....__.._..._____....._._..._._..__ -- _......_ Name Vehicle License Number Wind. River Environmental,, 46 Lizotte -Drive, Suite 1000, -Marlborou h, MA- 01752 Company ... ---- 7. Location where contents were disposed: Water Solutions Group: 35 Mozzone Blvd Taunton, MA 02780 Sergio Polanco 06/29/2026 Signature of Hauler Date _.__._.._.___--._____. _ —_— Signature of_ Receiving Facility(or attach facility reoeipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1