HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 RALEIGH TAVERN LANE 4/7/2024 Commonwealth of Massachusetts
City/Town of North Andover
-- _ 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: 0
200 Raleigh Tavern Lane MPer�
Address r� a
North Andover MA a`�� 1845
City/Town State ZiD Code
2. System Owner:
Debra & Raymond O'Brien
Name
200 Raleigh Tavern Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9783140032
Telephone Number
B. Pumping Record
1500.0
1. Date of Pumping Date 04/24/2024 Gaallonsllons 2 Quantity Pumped: 000
3. Component: ❑ Cesspool(s) ❑X Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑I Yes No If yes, was it cleaned? ❑X Yes No
5. Observed condition of component pumped:
System Operating Fine. Normal water level. Heavy 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 1500 gallons. Recommended No
Recommendation.
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
Marcus Lark 04/24/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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