HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 RALEIGH TAVERN LANE 7/6/2022 RECEIVED
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Commonwealth of Massachusetts ja 0 6 2022
City/Town of North Andover N OF NORTHANDOVER
A
System Pumping Record OHEALTHDEPARTMENT
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 in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
70 Raleigh Tavern Lane
Address
North Andover MA 01845
City/rown State Zip Code
2. System Owner:
Walter Soule,
Name
70 Raleigh Tavern Lane, 978-478-7888
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9784787888
Telephone Number
B. Pumping Record
1. Date of Pumping 05/06/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank Tight Tank ❑Grease Trap
Other(describe):
4. Effluent Tee Filter present? a Yes ❑ No If yes,was it cleaned? ❑X Yes No
5. Observed condition of component pumped:
System Operating Fiiie r7,,rmai water lev1, Haay., top Solids nnnd6� raro haft m
studge. Buth bafftens are intact. Main lint! Ctear. Fitter ts p-Leseut �uid lids been
cleaned as needed. Cover s secured. Pumped gallons. Recommended Boost
additive,CCLS additive.
6. System Pumped By:
Marcus Lark
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
05/06/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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