HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 141 CARLTON LANE 2/10/2023 RECENEL)
Commonwealth of Massachusetts FEB 10 2023
City/Town of North Andover OF NORTH ANDOVER
System Pumping Record TOWN EPARTM�taT
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:
141 Carlton Lane
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Erin Riccio
Name
141 Carlton Lane,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
8603787079 x
Telephone Number
B. Pumping Record
1. Date of Pumping 01/23/2023 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: cesspool(s) n Septic Tank ❑Tight Tank ❑Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes ❑ No If yes, was it cleaned? ❑X Yes No
5. Observed condition of component pumped:
gy tem not- nparAtingFine High wat level r bdode a* top solids Moderate bottom
beeir—
cleaned as needed. over s secured. Pumped 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
, s 01/23/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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