HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 LACONIA CIRCLE 10/18/2022 RECEIVED
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Commonwealth of Massachusetts OCT 18 2022
City/Town of North Andover
R System Pumping Record HE OF NORTH ANDOVER
y p 9 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:
130 Laconia Circle
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Gregory Schmidt
Name
130 Laconia Circle,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9785028311 x
Telephone Number
B. Pumping Record
1. Date of Pumping 09/16/2022 2. Quantity Pumped: 1000.0000
p g y p 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- Normal tr lc 1 Moderate ton Solids Moderate bottom
current tank is not designed to be use wit a i ter. Cover(s) secured. Pumped
1000 gallons. Recommended Boost additive,Wind River Septic System Treatment
additive.
6. System Pumped By:
Marcus Lark
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
09/16/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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