HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1317 SALEM STREET 6/7/2021 RECEIVED
a Commonwealth of Massachusetts
C JUN 0 7 2021
City/Town of
TOWN OF NORTH ANDOVER
i System Pumping Record HEALTH DEPARTMENT
V Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must be
suovantialiy 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 w th 310 Cf.1R 15.351.
A. Facility Information
1. System Location:
1317 Salem stree-L. _
Address
North Andover MA 01045
City/Town State ---__- Zip Code -_..
2. System Owner.-
Chris Orlich --
Name
1317 Salem street
Address(f different from location)
North Andover __- -_-__ MA __ ____ 01845
City/Town State Zip Code
9785943613
Telephone Number
B. Pumping Record
05/18/2021 1000.0000
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) 0 Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 11Yes 0 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
;zystAm Operating Fine isa1_warex leue',beau Moderate-bottom-.,—.-----------__
s3vdz 8ottr-bwff1:es are 1 . sserrt-cn the-:arsic;
current tam designe to use with a filter. Cover is s cured. Pumpea
1000gallon3. Recommended Boost additive,CCLS additive.
6. System Pumped By:
Marcus Lark 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 Distr_ct : 240 Charles Street_, North Andover, MA
05/18/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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