HomeMy WebLinkAboutSeptic Pumping Slip t'
Commonwealth of Massachusetts '
City/Town of North Andover
System Pumping Record . 26 Z024
Form 4 1,
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 ot``Healp Lo determine the form
they use.The System Pumping Record must be submitted to the local Board of Health or other approving author'((qwitfg 14
days from the pumping date in accordance with 310 CMR 15.351. `'b F�
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
City/Town State Zip Code
9786818934 x
Telephone Number
B. Pumping Record
1. Date of Pumping 09/06/2024 2. quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) 0 Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes 0 No If yes,was it cleaned? [:]Yes F] No
5. Observed condition of component pumped:
System Operating Fine. Normal water level. Light top solids. Moderate bottom
sludge. Both baffles are intact. Main line Clear. No filter is present on the
tank; current tank is not designed to be used with a filter. Cover(s) secured.
Recommended No Recommendation.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
South essex sewerage district: 50 Fort Ave, Po Box 989, Salem , MA 01970
Robert Herrick 09/06/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1