HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 TUCKER FARM ROAD 6/5/2023 Commonwealth of Massachusetts
r City/Town of North Andover N o�2q13
11 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 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:
91 Tucker Farm Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Pauline Hoenigsberg
Name
91 Tucker Farm Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9789850745
Telephone Number
B. Pumping Record
1. Date of Pumping 05/31/2023 2 Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) F Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes [X—] No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
System Operating Fine. Normal water level. Moderate top solids. Heavy bottom
sludge. Both baffles are intact. Main line Clear. No filter is present on the
tank; current tank is not designed to be used with a filter. Cover(s) secured.
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 Street, Bradford, MA 01835
05/31/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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