HomeMy WebLinkAboutSeptic Tank - - 925 FOREST STREET 11/10/2025 Commonwealth of Massachusetts
City/TownOf North Andover 7btvp
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the inf on must be
substantially the same as that provided here.Before using this form,check with your local Board of Healthlooeri a the form
i they use.The System Pumping Record must be submitted to the local Board of Health or other approving au I 'mhin 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
925 Forest Street
Address
North Andover MA 01845
City/Town State ZiD Code
2. System Owner:
Simonne Dolfe
Name
925 Forest Street
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Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787949355
Telephone Number
B. Pumping Record
1. Date of Pumping 10/01/2025 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank F]Tight Tank F] Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? R Yes RX No If yes, was it cleaned? n Yes n No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Septic system serviced. Filter not
present. Tank cannot be outfitted with filter. 1000 gallons removed. Moderate
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
using boost next pumping.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlb2.�q�k, MA 01752
Company
7. Location where contents were disposed:
NENO Yard: 163 -Western Ave, Gloucester, MA 01930
10/01/2025
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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