HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 141 CARLTON LANE 10/3/2022 �ECEIVE�'
Commonwealth of Massachusetts 32021
City/Town of North Andover �C pr1UUV�F'"
System Pumping Record �OWNOFNpePABV0eW
r` Form 4 HEA�FN
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:
141 Carlton Lane
Address
North Andover _ MA 01845
Citylrown State Zip Code
2. System Owner:
Bronwyn Boyle _
Name
141 Carlton Lane
Address(if different from location)
North Andover MA 01845
Cityrrown State Zip Code
6038099650 x_Cell
Telephone Number
B. Pumping Record
1. Date of Pumping 08/01/2022 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? ❑X Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System nGt Operating Eipa- No-Mal water I-evel Moderate top solids Moderate hottom
studge. Butli baffies are intact. Main line CleaL. Filtez is present and licts beeil
cleaned as needed. Cover s secured. Removed 1500 gallons. Recommended Boost
additive,Wind River Septic System Treatment additive,Pump Repairs.
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:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
' 08/01/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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