Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 757 TURNPIKE STREET 11/1/2021 Commonwealth of Massachusetts 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 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: 757 Turnpike Street Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: C&W Services/Stop & Shop Name 140 Kendrick Street, Building C West, Suite 201 Address(if different from location) Needham Heights MA 02494 City/Town State Zip Code 5714342034 Telephone Number B. Pumping Record 1. Date of Pumping 09/01/2021 2. Quantity Pumped: 4000.0000 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: T at le] F hnttn cl dl-. 7' tnn QC)l ids RL1th ]:.ffl S are intact Main tine eTear. No filtel is presteift On ttie tank, current tank is not designed to e used with a filter. over s secured. No 3rd party paperwork i e . 6. System Pumped By: Michael Graham Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835 09/01/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1