HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 MARIAN DRIVE 6/11/2024 <�, 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:
35 Marian Drive
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Allison Ray
Name
35 Marian Drive
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6034012466
Telephone Number
B. Pumping Record
1. Date of Pumping 06/11/2024 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. Moderate top solids. Heavy 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:
Marcus Lark
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Ipswich WWTP: 21 Fowlers Lane, Ipswich , MA 01938
Marcus Lark 06/11/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1