HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 946 OSGOOD STREET 3/21/2022 �ECE1V�t.:
<C\ Commonwealth of Massachusetts MAR 21 �02`t
City/Town/Town Of AN
o y North Andover 1004 HDEPA WEN'T �y
System Pumping Record HEA►-T
Form 4
s 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:
946 Osctood Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
China Blossom (Andover)
Name
946 Osgood Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786976080
Telephone Number
B. Pumping Record
1. Date of Pumping 01/24/2022 2. Quantity Pumped: 5000.0000
Date Gallons
3. Component: Cesspool(s) 0 Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? M Yes ❑X No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
e used with a filter. Cover(s) secured. No 3rd party paperwork i e . Pumped
gallons.
6. System Pumped By:
Marcus Lark
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
01/24/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record°Page 1 of 1