HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 93 TURNPIKE STREET 11/10/2025 Commonwealth of Massachusetts row,7 of
City/TownOf North Andover
over
System Pumping Record
Form 4 NOVI 0t DEP has provided this form for use by local Boards of Health.Other forms may be used �g� the information m us 25
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substantially the same as that provided here.Before using this form,check with your lo ealth to determine the form
they use.The System Pumping Record must be submitted to the local Board of Health or c PAVJ9&ft�ority within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
93 Turnpike Road
Address
North Andover MA 01845
City/Town
2. System Owner:
Rubicon
Name
125 Half Mile Road, Suite 201
Address(if different from location)
Red Bank NET 07701
City/Town State Zip Code
7322753434
Telephone Number
B. Pumping Record
1. Date of Pumping 10/03/2025 2. Quantity Pumped: 3000.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank F-1 Tight Tank o Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes 1/\l No If yes, was it cleaned? F-1 Yes F-1 No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Grease Tank system serviced. Filter not
present. Tank cannot be outfitted with filter. 3000 gallons removed. 3 inches of
bottom sludge. 3 inches of grease on top. 30 inches of water. System is at proper
working level. Both baffles/tees are intact. Main line is clear.
6. System Pumped By:
Jaime Rivera
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
NENO Yard: 163 Western Ave, Gloucester, MA 01930
--------------------......
10/03/2025
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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