HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 650 FOREST STREET 12/17/2025 Commonwealth of Massachusetts
City/Town0f North Andover
System Pumping Record
Form 4
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:
650 Forest Street
Address
North Andover MA 01845
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City/Town State_ Z QQ.d
2. System Owner:
Drew Archer
Name
650 Forest Street
Wddreii(if different from location)
North Andover MA 01845
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City/Town State Zip Code
5083801229
..........
Telephone Number
B. Pumping Record
12/17/2025 1. Date of Pumping 0.0000
'date------------------------ 2. Quantity Pumped: Gallons
3. Component: F] cesspool(s) F71 Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Fj Yes Q No If yes, was it cleaned? F]Yes n No
5. Observed condition of component pumped:
Could not get on driveway as it was covered in ice
Spoke with customer and they will call in when its clear.
See pics.
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:
.............
Marcus Lark 12/17/2025
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Signature of Hauler Date
.............
Signature of Receiving Facility(or attach facility receipt) Date
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