HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1317 SALEM STREET 7/18/2022 REGENED
Commonwealth of Massachusetts �uL 18 Z022
City/Town of North Andover NDO�ER
System Pumping Record TOwN OF NOET"A
_ Form 4 HEALTH DEPAR
TMENT
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:
1317 Salem street,
Address
North Andover MA 01845
City/Town State Zvi Code
2. System Owner:
Chris Orlich
Name
1317 Salem street,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9784718618 x
Telephone Number
B. Pumping Record
1. Date of Pumping 06/21/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) 0 Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes a No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
System Operating Eine- Normal water le-el- moderate tQP -alid2- moderate b,ttom
5tudye. Both baffies are intact. Maiii lizird Cleciz. No filter is present an the t:aiiki
current tank is not designed to be used with a filter. Cover s secured.
Recommended Boost additive,Wind River Septic System Treatment 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
06/21/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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