HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 RALEIGH TAVERN LANE 10/3/2022 EOF
Commonwealth of Massachusetts O�j 0 32022
City/Town of North Andover tij,f; ;'.
- System Pumping Record TOWN OF N'}'CpAR M�N�
Form 4 HEp�jH
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:
151 Raleicfh Tavern Lane,
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Brendan McCarthy
Name
151 Raleigh Tavern Lane,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9788356699 x
Telephone Number
B. Pumping Record
1. Date of Pumping 07/07/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: D Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes 0 No If yes, was it cleaned? 0Yes No
5. Observed condition of component pumped:
System Operating Fi, Normal uxater Moderate top selids Medexatp rr
,
current tank is not designed to be used with a filter. Cover s secure .
Recommended Boost additive,Wind River Septic System Treatment additive.
6. System Pumped By:
Ron Soucie III
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Gloucester WPCF: 50 Essex Avenue, Gloucester, MA 01930
07/07/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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