HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 RALEIGH TAVERN LANE 7/6/2022 DECEIVED
<CN Commonwealth of Massachusetts JUL 0 6 2022
City/Town of North Andover TCWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
M 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:
200 Raleigh Tavern Lane,
Address
North Andover MA 01845
Cityrrown State Zip Code
2. System Owner:
Debra & Raymond O'Brien
Name
200 Raleigh Tavern Lane,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6177334127 x
Telephone Number
B. Pumping Record
1. Date of Pumping 05/05/2022 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? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
S�'Stem Operating Fine Narmal wat-Q, 10"Q] MaHerate top solids moderata bottom
sludge. Buth bafftes ars intaut. Main line Ctear. Fi:tt:e.L is present and has been
cleaned as needed. Cover s secured. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Ron Soucie _
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
05/05/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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