HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 99 RALEIGH TAVERN LANE 10/3/2022 HECeNED
Commonwealth of Massachusetts OAT 3IV
City/Town of North Andover NORTH AND v
�1 System Pumping Record TowNeB
OF EPAATnn�
A�THD
41 Form 4 HE
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:
99 Raleigh Tavern Lane,
Address
North Andover MA 01845
Cityrrown State Zip Code
2. System Owner:
Yvette Bonin
Name
99 Raleigh Tavern Lane,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787712081 x
Telephone Number
B. Pumping Record
1. Date of Pumping 08/23/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) Fje� Septic Tank ❑Tight Tank ❑Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? ❑Yes ❑X No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
System OperatingFine Normal water 1 1 140d.0-ate top Sa1ids mnderat.e hat-tom
,
current tank is not designed to be used with a filter. over s secured. Remove
1500 gallons. Recommended Boost additive,Wind River Septic System Treatment
additive.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
08/23/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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