HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 RALEIGH TAVERN LANE 5/3/2023 RECEIVED
Commonwealth of Massachusetts
City/Town of North Andover 3M3
r _ System Pumping Record ��AY 0
�r Form 4 TOWN OF NORTH ANDOVER
v � g17H DEPARTMENT
DEP has provided this form for use by local Boards of Health.Other forms may be used,bii�mformation 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:
200 Raleigh Tavern Lane
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Debra & Raymond O'Brien
Name
200 Raleigh Tavern Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9783140032
Telephone Number
B. Pumping Record
1. Date of Pumping 04/21/2023 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? 0 Yes No If yes, was it cleaned? Yes LINO
5. Observed condition of component pumped:
System Operating Fine. Normal water level. Moderate top solids. Moderate bottom
sludge. Both baffles are intact. Main line Clear. Filter is present and has been
cleaned as needed. 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:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
04/21/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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