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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 946 OSGOOD STREET 11/1/2021 Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Imp 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: 946 Osgood Street Address North Andover MA 01845 Cityrrown State Zip Code 2. System Owner: China Blossom (Andover) Name 946 Osgood Street Address(if different from location) North Andover MA 01845 Cityrrown State Zip Code 9786976080 Telephone Number B. Pumping Record 1. Date of Pumping 09/15/2021 2. Quantity Pumped: 5000.0000 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? ❑Yes No 5. Observed condition of component pumped: Normal water l cl Soin hntt m sludge 50in to qolids Roth baffles are intact matil line etear. No ftiter is prestent on the tank, current tank is not designed tu-- e used with a filter. over s secured. No Jrd party paperwork i e . Pumped gallons of grease heavy solids top and bottom. 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 09/15/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1