HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 OLYMPIC LANE 2/23/2021 Commonwealth of Massachusetts RECEIVE®
City/Town of North Andover FEB 2 3 2021
System Pumping Record
,r
Form 4 'C",RD OF HEALTH
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:
151 Olympic Lane
Address -
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Rolfe & Edith Trevisan
Name
151 Olympic Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code ---
9786818934
Telephone Number
B. Pumping Record
1. Date of Pumping 01/29/2021 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑X No If yes, was it cleaned? Fj Yes No
5. Observed condition of component pumped:
wo'mal- laat— level light top Ticiht �)otLoin .9111dge Both baffles —e intact
e used wit a i ter. Cover s secure Recommen a Boost a hive, L a hive.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
01/29/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of North Andover FFB 2 3 2021
System Pumping Record
Form 4 L71
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:
151 Olympic Lane
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Rolfe & Edith Trevisan
Name
151 Olympic Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786818934
Telephone Number
B. Pumping Record
1. Date of Pumping 01/29/2021 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes FX� No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
System spot_. Operating Fine No" n-__Pplic abll o water level, Not Applicable top—solids
bottom sludge. Maim-ItTre N
the tank; current tank is not designed to-be used with a filter. over s secured.
Recommended Distribution Box/Manifold.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
0 1/2 9/2 0 2 1
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of North Andover FEB 2 3 2021
System Pumping Record
Form 4 C!`JID OF HEALTH
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:
151 Olympic Lane
Address
North Andover MA 01845
City/Town State _ Zip Code
2. System Owner:
Rolfe Trevisan
Name
151 Olympic Lane
Address(if different from location)
North Andover MA 01845
Cityrrown State Zip Code
9786818934
Telephone Number
B. Pumping Record
1. Date of Pumping 01/14/2021 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank Tight Tank R Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes 0 No If yes, was it cleaned? RYes No
5. Observed condition of component pumped:
High water level Light top solids Light bottom sludge Rath haffl,es are J-ntaZt-
Main line Clear. No filter is pre-�,R=11U U11 LALt2 Lki uuzrunt: tank is not designed to
e used with a filter. Cover(s) secure Repairs nee a Hig iqui eve in tan .
Pumped tank. Flush test flowing. Dug up outlet cover. Found line from outlet to D
box not working need to dig it up and chase back to fix probable break
Recommended Boost additive,CCLS additive.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
01/14/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1