HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 139 ROCKY BROOK ROAD 12/14/2020 Commonwealth of Massachusetts RFCFlVzD
City/Town of North Andover
DEC 1 4 20 System Pumping Record ?0
!' Form 4 rH �FNORTry
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the d Al p EVE
substantially the same as that provided here. Before using this form,check with your local Board of Health t0�Vj a 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:
139 Rocky Brook Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Rhonda Chicko
Name
139 Rocky Brook Road
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9787259449
Telephone Number
B. Pumping Record
1. Date of Pumping 11/12/2020 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 ❑X No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
sludge. Batli baffles are intact. Main line Cledr. Na ftiLtrL is present an ttie tank;
current tank is not designed to be used with a filter. Cover(s) secured.
Recommended Boost additive,CCLS additive.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
11/12/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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