HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 235 RALEIGH TAVERN LANE 10/10/2023 Commonwealth of Massachusetts
City/Town of North Andover OCT
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:
235 Raleigh Tavern Lane
Address
North Andover MA 01845
City/Town State Zia Code
2. System Owner:
Chris Hevey
Name
235 Raleigh Tavern Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
7816083763
Telephone Number
B. Pumping Record
09/05/2023 1500.0000
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Component: cesspool(s) 0 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 Operating Fine. Normal water level. Moderate top solids. Moderate 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.
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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