HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 COACHMANS LANE 8/3/2023 Commonwealth of Massachusetts
rsi City/Town Of North Andoverti�ti3
System Pumping Record PSG
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:
200 Coachmans Lane
Address
North Andover _ MA 01845
City/Town State _ Zia Code
2. System Owner:
Brian Roache _
Name
200 Coachmans Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6178722801 _
Telephone Number
B. Pumping Record
1. Date of Pumping 03/06/2023 2 Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank ❑ Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes X No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
System not Operating Fine. High 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.
Repairs needed: Pump or float repair. Pumped 1000 gallons. Recommended Pump
Repairs.
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:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
03/06/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1