Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 700 CHICKERING ROAD 10/12/2021 REc��v�D Commonwealth of Massachusetts City/Town of North Andover A�opvER System Pumping Record 1000 E 0Mf Form 4 ; 0 w 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 Chickering Road Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Ashland Farm at North Andover Name 700 Chickering Road Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9786831300 Telephone Number B. Pumping Record 1. Date of Pumping 08/17/2021 2'Quantity Pumped: 1000.0000 Date Gallons 3. Component: Cesspool(s) ©Septic Tank Tight Tank Grease Trap Other(describe): 4. Effluent Tee Filter present? Yes © No If yes, was it cleaned? YesEj No 5. Observed condition of component pumped: Narmal Watar 9 h rrnsludge- 2ir�top Sol ids Both baffles rga intact witri a riiter. No 3rd party paperwork i e . Pumped gallons of grease. 6. System Pumped By: Jason Tedesco 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 08/17/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1