HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 160 FARNUM STREET 10/3/2022 �L\ Commonwealth of Massachusetts
City/Town of North Andover OCZ 32022
System Pumping Record o�NOtTH H�,OcvE�
Form 4 SOWN DEPARTMENT
HEALTH
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:
160 Farnum Street,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Paul Olson
Name
160 Farnum Street,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786822097 x
Telephone Number
B. Pumping Record
1. Date of Pumping 07/05/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes ❑X No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
,
current tan 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:
Ron Soucie III
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
07/05/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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