HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 194 OLYMPIC LANE 7/6/2022 RECEIVED
Commonwealth of Massachusetts JUL 0 6 2022
City/Town of North Andover
WN OF NORTH
a - System Pumping Record TCHEALTHDEPARTMENT
R
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:
194 Olympic Lane
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Sarah and Ken Keogh
Name
194 Olympic Lane
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9785025535 xSarah
Telephone Number
B. Pumping Record
1. Date of Pumping 05/11/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes No If yes,was it cleaned? ❑-0 Yes No
5. Observed condition of component pumped:
S�,stem Operating Rine High water laval- Modelate top solids Heavj, bottom sludge
needed. Covers secured. Pumped gallons. Recommended Boost additive,CCLS
additive.
6. System Pumped By:
Marcus Lark
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
05/11/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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