HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 TUCKER FARM ROAD 10/18/2022 RECEIVED
Commonwealth of Massachusetts OCT 18 2022
City/Town of North Andover
System Pumping Record TOHEALLTH DOE ARTMENTER
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:
103 Tucker Farm Road,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Claire Cavanaugh
Name
103 Tucker Farm Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9783605603 x
Telephone Number
B. Pumping Record
1. Date of Pumping 09/29/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes FK-] No If yes,was it cleaned? ❑Yes No
5. Observed condition of component pumped:
System Operating Fine Normal watgli 10"el- moderate top solids modQrate hattom
current tan is not designed to be use wit a filter. Cover s secured.
Recommended Boost additive,Wind River Septic System Treatment additive.
6. System Pumped By:
Michael Graham
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
09/29/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1