HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 160 FARNUM STREET 6/7/2021 RECEIVED
Commonwealth of Massachusetts JUN 0 7 2021
City/Town of ""sor�h ndove�
System Pumping Record TOW ETHANDOT
HEAALTHLTH D DEPARTMENT
VER
Form 4
DEP has provided this farm 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 CNIR 15.351
A. Facility Information
1. System Location:
160 Farnur. Street
Address
North Andover MA
CityJTown State Zp ode _
2. System Owner:
Paul Olson
Name
160 Farnum Stree-
Address(if different from location)
North Andover _ MA _ 01845__ __-
Cityrrown state Zip Code
9786122097 xh __...
Telephone Number
B. Pumping Record
_
1. Date of Pumping Date/26/2021 2. Quantity Pum 1000.0000
ped: Ga tons
3. Component: F1Cesspool(s) F%_f_1 Septic Tank Tight Tank Grease Trap
Other (describe):
4. Effluent Tee Filter present? 0 Yes � No If yes. was it cleaned? Yes No
5. Observed condition of component pumped:
S}rstzm-Onuating.-Ei ater_leual_-uncle zatz__top solids- _
ffies-axe intact-.-Main _ o-fitter-is prsseTtt-an -the_ tank;
current--t tank is not designed to be used with i7 i ter, over s secured. tunpec�
1000 gallons. Recommended CCLS additive.
6. System Pumped By:
rcus 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 District : 240 Charles Street , North Andover, 24A
05/26/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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