HomeMy WebLinkAboutSeptic Pumping Slip - Septic Pumping Slip - 10 CROSSBOW LANE 9/4/2024 I
i
Commonwealth of Massachusetts
City/Town Of North Andover
n System Pumping Record
r` 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:
10 Cross Bow Lane
Address
North Andover MA 01.845
CityrFown State Zip Code
2. System Owner:
I
Jay Marconi
Name
10 Cross Bow Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
5088891482
Telephone Number
B. Pumping Record
09/05/2024 1000,0000
1. Date of Pumping Date 2. Quantity Pumped: Gatlons
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes 0 No If yes,was it cleaned? 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. No filter is present on the
tank; current tank is not designed to be used with a filter, Coverts) secured.
Recommended No Recommendation,
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, NIA 01.752
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
Robert Herrick 09/05/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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