HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 111 PHEASANT BROOK ROAD 11/10/2025 Commonwealth of Massachusetts Town of jVorM 4,
City/TownOf North Andover NOV 10 2025
System Pumping Record
Form 4 "ea"h
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the inforngampatt
substantially the same as that provided here.Before using this form,check with your local Board of Health to determMinek 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:
93 Turn Ike Road__..._-----
........................ ----------- ......................... ..............
Address
North Andover MA 01845
St zip.-Code.............................
2. System Owner:
Rubicon
............ .................... ------ -------...........
Name
125 Half Mile Road, Suite 201
................... .........................................
Address(if different from location)
Red Bank NJ 07701
............. —-—----------—-------------------
City/Town State Zip Code
7322753434
Telephone Number
B. Pumping Record
10/22/2 02 5 100.0000
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) F] septic Tank n Tight Tank r7/1 Grease Trap
14�nj
Other(describe):
.......... ............................. --------------.............................
4. Effluent Tee Filter present? n Yes nX No If yes,was it cleaned? F]Yes n No
5. Observed condition of component pumped:
3 Bay Sink. 6 inches of grease on top. 4 inches of water. 6 inches of bottom
sludge. 50 gallons removed. Both baffles/tees are intact. Gasket is in good
condition. Walls/bottom of trap in good condition. System is at proper working
level. Left 0 bottles of drain master. 16inches 50gallons. BOH Logs Signed.
Recommend Drain Cleaning. Dc for preventive maintenance on pipes and floor drains.
6. System Pumped By:
Robbie Hall
............................... ---------- ....................................... .............................................
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
----------------------------- .............
Company
7. Location where contents were disposed:
Water Solutions Group: 35 Mozzone Blvd . Taunton, MA 02780
....................... ....................... ............
Robbie Hall 10/22/2025
...........................-------- ......................--------------- ................. ............. .................................
Signature of Hauler Date
-Signature-of Receiving'-' ''" "Fa-cility-(or attach-facility-receipt)''' -- -- Da-to
t5form4,doc- 11/12 System Pumping Record-Page 1 of 1