HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 976 FOREST STREET 7/17/2025 �L Commonwealth of Massachusetts
City/Town Of North Andover row
n of/Voll
System Pumping Record
Form 4 Andover
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the info must be
substantially the same as that provided here.Before using this form,check with your local Board of H=ote r a the form
they use.The System Pumping Record must be submitted to the local Board of Health or other approving au it 740n 14
days from the pumping date in accordance with 310 CMR 15.351. h/An I't P
A. Facility Information '41411 DA'�'
1. System Location: I-Ijartm.n,
976 Forest Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Tami Coughlin
Name
976 Forest Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787660866
Telephone Number
B. Pumping Record
I. Date of Pumping 07/17/2025 1500.0000
2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) 57 Septic Tank F-1 Tight Tank R Grease Trap
141nd
F-] Other(describe):
4. Effluent Tee Filter present? r-]Yes rX-j No If yes, was it cleaned? ❑Yes F-� No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Septic system serviced. Filter not
present. Tank can be outfitted with filter - Sold Onsite. 1500 gallons removed.
Light sludge on bottom of tank. Moderate amount of 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:
KENO Yard: 163 West-ern Ave, Gloucester, -MA-01-930
Marcus Lark 07/17/2025
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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