HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 OLYMPIC LANE 10/14/2025 Commonwealth of Massachusetts
City/TownOf North Andover Town of NOfth Andover
System: Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the informati2glul 4 2025
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 oth pproving authority within 14
days from the pumping date in accordance with 310 CMR 15.351. Realth
A. Facility Information nt
1. System Location:
151_.q1_y2jR'Lq.'-Lan.e.
Address
North Andover MA 01845
Cityrrown t
..............
2. System Owner:
Rolfe and Edith Trevisan
.4am.e ........................... —--------------------
_15,1 Olvmpic Lane
Addre;���ii-dil�-re-n-t-f-r-"o"m—lo-c--a--ti--o n-)----------
North Andover MA 01845
City/Town State Zip Code
9786818934
Telephone Number
B. Pumping Record
1. Date of Pumping .0 9/25/2025 2. Quantity Pumped: 1500.0000
DateGallons
3. Component: 0 Cesspool(s) Septic Tank F-1 Tight Tank Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? []Yes No If yes,was it cleaned? F-1 YesFj No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Septic system serviced. Filter not
present. Tank cannot be outfitted with filter. 1500 gallons removed. Light sludge
on bottom of tank. Light top solids in tank. System is at proper working level.
Both baffl.es/tees are intact. Main line is clear. Recommend using boost next
pumping.
6. System Pumped By:
Michael Graham
Name— Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
............
Company
T. Location where contents were disposed:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
Michael Graham 09/25/2025
- �i_ u-- -..........--------------------------------------------------------------- ,- --..........§gnaireof Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4,doc-11/12 System Pumping Record-Page 1 of 1