HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 111 PHEASANT BROOK ROAD 10/2/2023 (2) Commonwealth of Massachusetts
F City/Town of North Andover
System Pumping Record
% 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:
111 Pheasant Brook Road
Address
North Andover MA 01845
City/Town State p Code
2. System Owner:
Denis Plourde
Name
111 Pheasant Brook Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
5085960187
Telephone Number
B. Pumping Record
1. Date of Pumping 10/02/2023 2 Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank ❑ Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 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. No filter is present on the
tank; current tank is not designed to be used with a filter. Cover(s) secured.
Recommended No Recommendation. Recommend using boost next pumping.
6. System Pumped By:
Michael Graham
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
10/02/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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