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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 93 TURNPIKE STREET 2/10/2022 RECEIVED Commonwealth of Massachusetts City/Town of North Andover FEB 10 2022 System Pumping Record .)RTN Form 4 r�— Y E ANDOVEFt PARTMENT 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 CM 15.351. A. Facility Information 1. System Location: 93 Turnpike Road Address North Andover MA 01845 Cityrrown State Zip Code 2. System Owner: Rubicon Name 125 Half Mile Road, Suite 201 Address(if different from location) Red Bank NJ 07701 Cityrrown State Zip Code 7322753434 Telephone Number B. Pumping Record 1. Date of Pumping 10/14/2021 2. Quantity Pumped: 3000.0000 Date Gallons 3. Component: ❑ Cesspool(s) 0 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: Narmal water 21-I hot-t CarFl--2 edge !in t-op solids Roth b,ffles a,Q intact Main iina ete.L.L. Na fitter is p-Lesent on the tank; cari-eilt tank is not designed ru e used with a filter. Covers secured. No 3rd party paperwork i e . Remove 3000 gallons. 6. System Pumped By: Robert Herrick Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: 163 Western Ave, Gloucester, MA 01930 10/14/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1