Loading...
HomeMy WebLinkAboutSepitc Tank - Septic Pumping Slip - 267 CHICKERING ROAD 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: 267 Chickering Road Rte 125 Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Restaurant Ninety Nine Name 14A Gill Street, Address(if different from location) Woburn MA 01801 City/Town State Zip Code 8664618372 x4 Telephone Number B. Pumping Record 1. Date of Pumping 09/02/2021 2. Quantity Pumped. 2500.0000 Date Gallons 3. Component: Cesspool(s) © Septic Tank ❑Tight Tank Grease Trap Other(describe): 4. Effluent Tee Filter present? El Yes © No If yes, was it cleaned? Yes ❑ No 5. Observed condition of component pumped: Ljormal w at 1 1 ]Bin bottom sludge l l 'n ton Solids Roth baffles are intact M&ill iillt-_ Ctk-_a_L. NU fittt-L ib PLUbUnt on Ltie tank, current tank is not de-signed to e used with a filter. Covers secured. No 3rd party paperwork i e . Extremely solids on top and bottom pumped 2500 gallons. 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 09/02/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1