HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 OLYMPIC LANE 7/6/2022 RECEIVED
2022
Commonwealth of Massachusetts 3UL 0 6
City/Town of North Andover lC r• �JB'rH ANDOTER
System Pumping Record az�LTr1DEPARTME"
Form 4
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
City/Town State Zip Code
2. System Owner:
Rolfe & Edith Trevisan
Name
151 Olympic Lane,
Address(if different from location)
North Andover MA 01845
CityfTown State Zip Code
9786818934 x
Telephone Number
B. Pumping Record
1. Date of Pumping 04/11/2022 2 Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) FK� Septic Tank Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes ❑X No If yes, was it cleaned? 11Yes ❑ No
5. Observed condition of component pumped:
System operating Fine Norpal watal: lavel- Light tGp sQlids Light bottom oludge
tank is not designed to be used with a filter. Cover(s) secured. Recommended Boost
additive,CCLS additive.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
-� 04/11/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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