HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 3/16/2026 �� Commonwealth of Massachusetts Tom taf �17 6 r r(�,i ta,r
City/TownOf North Andover
System Pumping Record
Form 4 APR 14 2026
DP 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 Cher a� I within 14
days from the pumping date in accordance with 310 CMR 16.351.
A. Facility Information
1. System Location:
18.Q1T,urn _ike Street
Address
North Andover MA 01845
City/Town -$JpLe 2112-C
2. System Owner:
.P-LreL Su
l OG - Sutton Hill GEN
Name
7301 West Champions Way .................
-Address(if"different from location)
Milwaukee Wi 53223
—------------ ------------ ....... .. ...
CityfTown State Zip Code
7042820530
Telephone Number
B. Pumping Record
1. Date of Pumping .03/16/2026 ........ 1000.0000
Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? R Yes RX No If yes, was it cleaned? R Yes R No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Main line is clear. Both baffles/tees are intact.
System is at proper working level. 48 inches of water. 2 inches of grease on top. 3 inches of
bottom sludge. FOG 9%. 1000 gallons removed. Filter not present. Tank cannot be outfitted
with filter. Grease Tank system serviced.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
MEMO Yard: 54 Knox Trail, Acton, MA 01720
Robert Herrick 03/16/2026
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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