HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 540 BOXFORD STREET 10/10/2023 �, Commonwealth of Massachusetts
513- City/Town of North Andover ��1013
VS � System Pumping Record �C
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:
540 Boxford Street,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Adam Bolduc
Name
540 Boxford Street,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6179229500 x
Telephone Number
B. Pumping Record
1. Date of Pumping 09/27/2023 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? ❑X Yes No If yes, was it cleaned? �Yes No
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. Pumped 1000 gallons. Recommended No
Recommendation. Recommend adding Treatment. Please visit
https://portal.wrenvironmental.com/ to purchase online.
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
09/27/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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