HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1317 SALEM STREET 9/7/2021 Commonwealth of Massachusetts
City/Town of North Andover
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 you((����?? th to determine the form
they use.The System Pumping Record must be submitted to the local Board of Hea�hD���wng authority within 14
days from the pumping date in accordance with 310 CM 15.351.
A. Facility Information
1. System Location: OF NORTH ANoOy�
TO NTH DEPARTMENT
1317 Salem street
Address
North Andover MA 01845
City/Town State Zia Code
2. System Owner:
Chris Orlich
Name
1317 Salem street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9785943613
Telephone Number
B. Pumping Record
1. Date of Pumping 05/18/2021 2. Quantity Pumped: 100_0.0000
Date Gallons
3. Component: Cesspool(s) F)CI Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? 0 Yes No
5. Observed condition of component pumped:
System npprAting Fine mnrmaj W--t-er Heavy top snlids lxloderate bottom
sludge. Both bdffie5 dZe ilItCLQt. Maill tine elUdL. NQ filtt:a ib pLt�bellt U11 tile tctLikr
current tank is not designed to be used with a filter. Cover(s) secured. Pumped
1000gallons. 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 District : 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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