HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 OLYMPIC LANE 2/23/2021 (5) Commonwealth of Massachusetts RECEIVED
City/Town of North Andover FFB 2 3 2021
System Pumping Record
Form 4 003-u44dge m
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
Citylrown 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? ❑Yes No
5. Observed condition of component pumped:
System not Operating Fine Not Applicable water I-evel- Not AppliCable top solids
Nut Appliudble mttom--s±udge. -cable _No ftiter is presmit oil
the tank; current tank -is not designe to e used with--a fi ter. Covers secure .
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:
,..� 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
a ; City/Town of North Andover FEB 2 3 2021
System Pumping Record
/1 Form 4 20 -BIRD OP F€ ALTH
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
Citylrown 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) N] Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? ❑Yes n No
5. Observed condition of component pumped:
Normal water level lighL top solids Light hottc�)ffl 21-udge Both baffles are int-act
Main line . No ftlter--±s-present 6n the-tank- current tank is not designed to
e used with a filter.-Cover(s) secured Recommended Boost additive,CCLS a itive.
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
City/Town of North Andover FEB 2 3 2021
Amft System Pumping Record
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 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
Cityrrown State ------- Zip Code
2. System Owner:
Rolfe & Edith Trevisan
Name
151 Olympic Lane
Address(d different from location)
North Andover MA 01845
City/Town State Zip Code
9786818934
Telephone Number
B. Pumping Record
1. Date of Pumping 01/22/2021 _ 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) 0 Septic Tank ❑Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? R Yes a No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
Not Applicable water Not Applicable top sWids Nnt Applicahle hottom
-App-tt _ tarik; currant tank
is not designed to be used with a filter. Cover s secured. Tank was empty upon
arrival. Recommended No Recommendation.
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:
.•ok 01/22/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1