HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 267 CHICKERING ROAD 3/21/2022 SeceNED
,L, Commonwealth of Massachusetts MAR 21IV
/Cit Town of
y North Andover NORTH pNpOVER
System Pumping Record TO HEALTHDEFP'Ft NT
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:
Phil Gagne Ninety Nine Restaurant
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 12/16/2021 2. Quantity Pumped: 3500.0000
Date Gallons
3. Component: Cesspool(s) FK� Septic Tank ❑Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes N] No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
Normal waterlevel 36in IDottom sludge 36in top solids Roth bafflesa e intact
e used with a filter. Cover(s) secured. No 3rd party paperwork i e . Water leie
normal no filter present baffles intact main line clear heavy solids and sludge
backwash 2xs wasn't able to get heavy hard solids out, recommend high velocity
jetting and drainmaster to prevent continues heavy hard solids pumped 3500 gallons
6. System�Pumped Byc�
Geoffrey Howard
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
12/16/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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