HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 LACONIA CIRCLE 1/25/2021 RECEIVED
Commonwealth of Massachusetts
City/Town of North Andover JAN 25 ?0?1
System Pumping Record TOWN OF NORTH ANDUVER
Form 4 HEALTH DEPARTMENT
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:
80 Laconia Circle
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Marianne Jenkins
Name
80 Laconia Circle
Address(if different from location)
North Andover MA 01845 _
City/Town State Zip Code
6179740002
Telephone Number
B. Pumping Record
1. Date of Pumping 12/02/2020 2. Quantity Pumped: 1000.0000
Date Gallons
3_ Component: Cesspool(s) Septic Tank Tight Tank ❑Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? YesO No If yes, was it cleaned? 0 Yes No
5. Observed condition of component pumped:
But:h bafflez� are not intact. Main line eiear. Filter is present and fids been
cleaned as needed. Covers secured. Repairs needed: Small repairs to come back and
fix outlet it fell off when tech removed filter to clean. Recommended outlet Tee.
6. System Pumped By:
Robert Hall
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
?, 12/02/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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