HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 267 CHICKERING ROAD 3/21/2022 (3) �ECENEU
Commonwealth of Massachusetts MAR 212022
City/Town of North Andover F
System Pumping Record TOWN OFt4pRTHA"Do"E
Form 4 HEALTH DEPARTMENT
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 02/17/2022 2 Quantity Pumped: 3500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes F)(] No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
Normal water Java] 1-21-n bottom 21iadge 12in top sGljds Both haffle2 are intaat
Maiii time Clear. No filtez is prasent an the tank; CULLIdIft tank is not clesigned to
e used with a filter. Cover(s) secured. No 3rd party paperwork i e . Very eavy
solids. Combo truck needed next service.
6. System Pumped By:
Justin Beaudoin
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
Berwick Sewer District : 2 Power House Road, Berwick, ME 03901
02/17/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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