HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 63 CROSSBOW LANE 6/6/2024 <�, 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:
63 Crossbow Lane
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Edith Duffy
Name
63 Crossbow Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
5083359182
Telephone Number
B. Pumping Record
1. Date of Pumping 05/16/2024 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) FX-] Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? 0 Yes No
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 No Recommendation.
6. System Pumped By:
Jonathon Colson
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
Jonathon Colson 05/16/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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