HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 RALEIGH TAVERN LANE 4/2/2025 Commonwealth of Massachusetts
w� City/Town of North Andover
s
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:
200 Raleigh Tavern Lane
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Debra & Raymond O'Brien
Name
200 Raleigh Tavern Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9783140032
Telephone Number
B. Pumping Record
1. Date of Pumping 04/21/2025 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑X Yes ❑ No If yes, was it cleaned? ❑X Yes ❑ 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. Recommend adding Treatment. Please visit www.bookmyseptic.com
to purchase online.
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:
HaverHill Disposal Site: 40 S. Porter Street, Bradford, MA 01835
Marcus Lark 04/21/2025
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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