HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 TUCKER FARM ROAD 5/8/2026 �, Commonwealth of Massachusetts T11111 of NOrth
City/TownOf North Andover JUN 18 1026
System Pumping Record
Form 4 HO-alth e
V) D
�C� J` D�P has provided this form for use by local Boards of Health,Other forms may be used,but the Information must be 'P,9 rtn', n t
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:
67 Tucker Farm Road
.........................
Address
North Andover MA 01845
2. System Owner:
Daniel Shafrir - Pr e
Name
67 Tucker Farm Road
.......................................
Address(if different from location)
North Andover MA 01845
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City/Town State Zip Code
8573211539
................................
Telephone Number
B. Pumping Record
1. Date of Pumping 05/08/2026 -- 2. Quantity Pumped: 1500.0000
Date gallons
3. Component: Ej cesspool(s) FXJ Septic Tank n Tight Tank R Grease Trap
F-1 Other(describe):
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4. Effluent Tee Filter present? 1:1 Yes Z No If yes,was it cleaned? E]Yes F-1 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. 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,
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:
Greater Lawrence Sanitary District : 240 Charles Street North Andover, MA
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Marcus Lark 05/08/2026
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Signature of Hauler Date
--'—ta,c-,h facility receipt) Date
,-- - - ------------------------------------------------------------------------------
Signature of Receiving Facility(or at
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