HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 700 CHICKERING ROAD 6/7/2021 Commonwealth of Massachusetts
r� City/Town of
System Pumping Record
Form 4
.rt1i DEP his prov,ded 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 us ng this form,check with your local Board of Health to *gnine the fora,
iney use.The System Pumping Record must be submitted to the local Board of Health or other � "°Nithin 14
days from the pumping date in accordance with 310 Ch1R 15.351.
A. Facility Information JON 0
1. System Location: THANDOV�
fpW�`I OF NOR
700 Cickerig_. Road _ HFALTHDEPARTME
Address
North Andover MA 01845
CityfTo►un State
2. System Owner:
Ashland Farm at North Andover
Name
700 C:hickgring Road __------
Address(if different from location)
North Andover MA
01845
City/Town State Zip Code
9786831300
Telephone Number
B. Pumping Record
05_/0.9/202i 1000.0000
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Component.- Cesspool(s) F%_11 septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes F)-(] No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
:azzx�t v:ate: 'eve, .- in ba;t:r n--sl dget i n tc.
MaiTr-tiTte--Clear _Na_ iter-is esertt- - ank-carr-try cuzfi tea
with a 1-ter:-C6verts secured. No 3rd party papers.or fi a Heavy solids and
modezate sludge no filter present pumped 1000 gallons cover secure.
6. System Pumped By:
Anthony Snow
Name Vehicle license Number
Wind River Environmental, PLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company — _ ._.._.
7. Location where contents were disposed:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
05/09/2021
------------- -----
Signature of Hauler Date
Signature of Receiving Facility far attach facility receipt) fie
15form4.doc- 1'112 System Pumping Record•Page 1 of i