HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 RALEIGH TAVERN LANE 4/27/2026 <C\ Commonwealth of Massachusetts
V CitY/TownOf North Andover
System Pumping Record
Form 4
�5) 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 15.361.
A. Facliffil Information
j 1. System Location:
200 Raleigh Tavern Lan
............... ------------- ............................
Address
North Andover MA 01845
......................................
City/Town 20 ................
2. System Owner:
Debra and Raymond O'Brien - Debra & Raymond O'Brien... ......... -—--------
Name
200 Raleigh Tavern Lane
........................... ..................................... ........
Address(if different from location)
North Andover MA 01845
-61 ..........-.-......................
own State Zip Code
9783140032
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Telephone Number
B. Pumping Record
04/27/2026 1500.0000
1. Date of Pumping bate----- 2. Quantity Pumped: Gal.Ions ...................
3. Component: Cesspool(s) Septic Tank F]Tight Tank n Grease Trap
Other(describe):
................. ............ ............-------
4. Effluent Tee Filter present? nX Yes n No If yes, was it cleaned? nX Yes n No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Septic system serviced. Filter is present and was
cleaned. 1500 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 adding Treatment. Please visit www.bookmyseptic.corft 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:
HaverHill Disposal Site: 40 S. Porter Street, Bradford, MA 01835
Marcus Lark 04/27/2026
Signature of Hauler —-------- Date
Signature of Receiving Facility(or attach facility receipt) Date
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