HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 68 LACONIA CIRCLE 2/10/2023 �ECEIVE�
Commonwealth of Massachusetts FEg 102023
_ City/Town of U No c�►A���jevv
North Andover F KTM T
System Pumping Record °N � pa
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:
68 Laconia Circle,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Robert Brown
Name
68 Laconia Circle,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6172335341 x
Telephone Number
B. Pumping Record
1. Date of Pumping 01/11/2023 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? Yes No If yes,was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System-operating Fine Norm-1- watar l al Moderate top solids Heavy bottom
current tank is not designed to be used with a tilter. over s securea. Pumped
1500 gallons. Recommended No Recommendation.
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
/' 01/11/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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