HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1216 SALEM STREET 6/17/2026 Town Of i,, 4h 4ndover
Commonwealth of Massachusetts JUL -2 2026
p City/Town Of North Andover
qry System Pumping Record
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Form 4 n
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must be elit
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:
1216 Salem Street,
Address
North Andover MA 01845
City/Town
2. System Owner:
Carl Gustenhoven _ Prima v Home
................ —---------
Name
1216 Salem Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9797784695
Telephone Number
B. Pumping Record
1. Date of Pumping 06/17/2026 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: FI 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. Moderate amount of top solids in tank. Moderate sludge on
bottom of tank. 1500 gallons removed. Filter not present. Tank cannot be outfitted with
filter. Septic system serviced.
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
Marcus Lark 06/17/2026
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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