HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 68 LACONIA CIRCLE 1/16/2025 Cn[�00C]DVVeBKhnfK8asSarhUse�s
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System Pumping Record
Form 4
oEphas provided this form for use by local Boards of Health.Other forms may be used,but the informa i In
substantially the same as that provided here.Before using this form,check with your local Board of Health to doeteft
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A. Facility Information
1. System Location:
68 Laconia Circle,
Address
North Andover M& 01845
City/Town State Zip Code
2. System Owner:
Robert Brown
Name
68 Laconia Circle,
Address(if different from location)
North 01845
City/Town State Zip Code
6172335341 a
Telephone Number
B. Pumping Record
Vl I50O-O000
1. Dmb�ofPum0inA Date2. []uunUhYpumP�d� Gallons
3. Component: F-lCeaspon|(e) Septic Tank Tight TankGrease Trap
Other(describe):
�� �� �� ��
4. EfUuen�TaeFi|terpn*ment? L_JYo� &�JNo |fyea. wuoitc|aaned? L_|YoaL_] No
5. Observed condition of component pumped:
Cover was aoneoneu and properly oeuozeu. Septic system serviced. Filter not
present. zaox cannot be outfitted with filter. 1500 nazzoom removed. Light sludge
on bottom of tank. Light top solids in tank. System in at proper working level.
Both baffles/tees are intact. Maio line is clear.
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:
mENO Yard: 163 Western Ave, Gloucester, Ma 01930
mazonn Lark 0I/16/2025
Signature ofHauler Date
Signature u(Receiving Facility(or attach facility receipt) oem
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