HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 700 CHICKERING ROAD 3/21/2022 aEGE1VE®
--------------------
Commonwealth of Massachusetts MAR 21�022
City/Town of North Andover TNANpONSa
gw
Syst4em Pumping Record Novo FI to aTm
r Form
`M 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:
700 Chickering Road
Address
North Andover MA 01845
Cityrrown State Zip Code
2. System Owner:
Ashland Farm at North Andover
Name
700 Chickering Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6035050630 x
Telephone Number
B. Pumping Record
1. Date of Pumping 02/14/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) ❑X Septic Tank Tight Tank 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:
Na mal urater level 2in, bottom Jin top solidsRoth baffles 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
02/14/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1