HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 700 CHICKERING ROAD 9/7/2021 Commonwealth of Massachusetts
;s City/Town of North 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 in o �
substantially the same as that provided here.Before using this form,check with your local Board 4=determine the form
they use.The System Pumping Record must be submitted to the local Board of Health or other approving autho ri y.,w in 14
days from the pumping date in accordance with 310 CMR 15.351. lr
A. Facility Information �FNop',vi 0
vE
1. System Location: T�HOLTHpEPARTMENT
700 Chickering Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Ashland Farm at North Andover
Name
700 Chickerinct Road
Address(if different from location)
North Andover _ MA 01845
City/Town State Tap Code
9786831300
Telephone Number
B. Pumping Record
1. Date of Pumping 05/09/2021 2. Quantity Pumped: 1000.0000
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:
Normal wate- -Ievei 2in bottom sludge 4in top solids Both baffles are intact
Main Tine Clear. No fiTter is pmesent on the- tank; cunrent: tank can be uut�fitted
with a filter. Cover(s) secure No 3rd party paperwork i e . Heavy solids and
moderate sludge no filter present pumped i.000 gallons cover secure.
6. System Pumped By:
Anthony Snow
Name 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
05/09/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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