HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 151 OLYMPIC LANE 4/5/2021 Commonwealth of Massachusetts
f City/Town of North Andover
h� System Pumping Record 5 ; Form 4
: v 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 03/25/2021 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank X❑Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? M Yes FX-] No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
sludge. Maim tine Nut Apptiucib±e . No filter is presexir- Un t:he tank; cuzzent tdnk
is not designed to be used wit filter. Cover(s) secured. Need to return to
finish work. Recommended No Recommendation.
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:
03/25/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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