HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 131 CRICKET LANE 10/10/2023 Commonwealth of Massachusetts
City/Town of North Andover ��� 1pti013
a _ _ System Pumping Record
Form 4
J'y�V f 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:
131 Crickett Lane
Address
North Andover MA 01845
City/Town State Zia Code
2. System Owner:
Rex Pajela
Name
131 Crickett Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9788524163 xCell
Telephone Number
B. Pumping Record
1. Date of Pumping 09/05/2023 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? FX—]Yes No If yes, was it cleaned? ❑X Yes 0No
5. Observed condition of component pumped:
System Operating Fine. Normal water level. Light 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:
Robert Herrick
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
09/05/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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