HomeMy WebLinkAboutSeptic Pumping Slip - 107 Gray St - 11/25/2024 - Septic Pumping Slip - 107 GRAY STREET 11/25/2024 Commonwealth of Massachusetts
City/TownOf 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:
_L0'j_Gray S t r e
Address
North Andover MA 01845
City/Town ------
2. System Owner:
_O�la_Rotaru
Name
107 Gray— Street
Addre
ss ss(if different from location)
North Andover MA 01845
City/Town State Zip Code
8573739257
Telephone Number
B. Pumping Record
1. Date of Pumping 11/25/2024 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: F-1 Cesspool(s) septic Tank F]Tight Tank n Grease Trap
Other(describe):
4. Effluent Tee Filter present? nX Yes n No If yes, was it cleaned? Yes n No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Septic system serviced. Filter is present
and was cleaned. 1500 gallons removed. Light sludge on bottom of tank. Light top
solids in tank. System is at proper working level. Both baffles/tees are intact.
Main line is clear.
6. System Pumped By:
Marcus Lark
Noma -i�ekicle--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 11/25/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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