HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 315 SOUTH BRADFORD STREET 3/21/2022 AECE1wEa
Commonwealth of Massachusetts 101
City/Town of MAR vk
North Andover pO�E
System Pumping Record toWNoiNOE M�`''j
Form 4 HEA1-
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:
315 South Bradford Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Smolak Farms
Name
315 South Bradford
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786826332 xEXT 0
Telephone Number
B. Pumping Record
1. Date of Pumping 12/06/2021 _ 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: cesspool(s) ❑ Septic Tank Tight Tank ❑X Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
-NO al water 1 1 4j-n bottom sl dge !jn top solicis Both hafflas are intact
e used with a filter. Cover s secured. No 3rd party paperwork i e . Remove
1000 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
12/06/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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