HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 63 CROSSBOW LANE 6/9/2026 Town Of N011h AndOver
Commonwealth of Massachusetts JUL - 2 2026
(,4 City/TownOf North Andover
System Pumping Record Health Department
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:
63 Crossbow Lane—
Address
North Andover MA 01845
City/Town 3AMP--- zip Code
2. System Owner:
Edith Duff --- Primary Home
Name
63 Crossbow Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
5083359182
Telephone Number
B. Pumping Record
1. Date of Pumping 06/09/2026 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑Cesspool(s) Septic Tank F]Tight Tank Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? IN-']Yes [--] No If yes, was it cleaned? Q Yes F-1 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. Light top solids in tank. Light sludge on bottom of tank.
1500 gallons removed. Filter is present and was cleaned. Septic system serviced.
6. System Pumped By:
Jonathon Colson
-i4em—e —Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough,--MA
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
Jonathon Colson 06/09/2026
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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