HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 3/10/2021 Commonwealth of Massachusetts
- = North Andover
CitY/Town of aR ,gyp 201
r'
System Pumping Recordccr�
Form 4 �
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:
700 Chickerina Road
Address ---- -_
North Andover MA 01845
Cityrrown -
State Zip Code_
2. System Owner:
Ashland Farm at North Andver
--_._ --
Name o --
700 Chickering Road
Address(if different from location) -
North Andover MA01895
ClWown
State - — by Cods
9786831300
Tebptwne Number
B. Pumping Record
1. Date of Pumping r,i15/2021Date 2• Quantity Pumped: 1_000.0000
Gallons
3. Component: Cesspools) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes a No If yes, was it cleaned? MYes No
5. Observed condition of component pumped:
-Normal -wa-ter--levIal-. Gia-i:o ;orn sludg th-baffles-are-a.ntact
Main ttile rent ull ttie t4i S-nOt'-cie S i gnE'd-tII—
e use wit a ter, over s secure -_
6. System Pumped By:
Michael Graham
ame ---
Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company --_
7. Location where contents were disposed:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
- _---- _ 02/15/2021
Signature of Hauler - — ---
Date
Signature of Receiving Facility(or attach facility receipt) Date
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