HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 148 STONECLEAVE ROAD 7/13/2026 Commonwealth of Massachusetts
C nnf North Audover
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—� -- Pumping�� Record
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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 yonn,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 within14
days from the pumping date in accordance with 310CMR15.351.
A. Fac~U`*nm Information
1. System Location:
148 3tooeoleave Road
Address
North Audover M& 01845
Cityrruwn State Zjp Code
2. System Owner:
Ben Hall-Seelig Primary Home
Name
I48 StooecIeave Road
Address(if different from location)
North Andover M& 0I845
City/Town State Zip Code
4136872024
Telephone Number
B. Pumping Record
07/l]/2026 1000 O000
1. D�t�ofPumping Date �� (]u�ntitypump�d� Go||ums'
3. Component FlCesapoo|(s) F771 Septic Tank F--|Tight Tank [ � Grease Trap
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Other(describe):
_ ` '�
4. Effluent Tee Filter present? F--|Yes No |f yes, was itcleaned? R Yes F—lNo
5. Observed condition of component pumped:
Cover was accessed and nznpezlv secured. Septic xxntam serviced. Filter not nzeoent' Tank
cannot be outfitted with filter. zoon gallons removed. Light aloune no bottom of tank. Light
top solids in tank. System is at nron*z working level. Inlet baffle/tee is intact - outlet
baffle/tee is not intact. Recommend outlet repair. Main line is clear.
O. System Pumped By:
Jonathon Colson
Noma Vehicle License Number
Wind River Environmental, 46 Liontte Drive Suite 1000 Marlborough, MA 01752
Company
7. Location where contents were disposed:
NE0O Yard: I63 Western Ave, Gloucester, M& Ol93O
Jouatboo Colson
07/l3/2U26
Signature n/Hauler oau*
Signature nv Receiving Facility(or attach facility receipt) Date
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