HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 LOST POND LANE 5/3/2023 Commonwealth of Massachusetts
City/Town Of North Andover RECENED
System Pumping Record
Form 4
'M DEP has provided this form for use by local Boards of Health.Other forms may be used,but the informaaon,,gw �1E
substantially the same as that provided here.Before using this form,check with your local �pg4�dtLMk �i M -ihe form
they use.The System Pumping Record must be submitted to the local Board of Health or othsr{ 1t�b��Fiority within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
96 Lost Pond Lane
Address
North Andover MA 01845
City/Town State Zip Code
2.• System Owner:
Paul Wolmering
Name
96 Lost Pond Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6178033671
Telephone Number
B. Pumping Record
1. Date of Pumping 04/13/2023 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 a No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
System Operating Fine. Normal water level. Light top solids. Light bottom sludge.
Both baffles are intact. Main line Clear. No filter is present on the tank;
current tank can be outfitted with a filter. Cover(s) secured. Shared driveway.
Removed 1,500 gallons. 2 hoses required to complete this job. Cap is located to
the right hand side of the house by the patio in the mulch. 4 inches below grade.
6. System Pumped By:
Ronnie Soucie III
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
04/13/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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