Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 757 TURNPIKE STREET 4/19/2022 RECEIVED ........... Commonwealth of Massachusetts APR 19 2022 City/Town of North Andover Sstem Pumping pin J Record TOWN OF NORTH ANDOVER a Form 4 HEALTH DEPARTMENT 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: 757 Turnpike Street Address North Andover MA 01845 Citylrown State Zip Code 2. System Owner: C&W Services/Stop & Shop Name 140 Kendrick Street, Building C West, Suite 201 Address(if different from location) Needham Heights MA 02494 Cityrrown state Zip Code 5714342034 x Telephone Number B. Pumping Record 1. Date of Pumping 03/11/2022 2. Quantity Pumped: 8000.0000 Date Gallons 3. Component: ❑ Cesspool(s) © Septic Tank Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? Yes 0 No If yes, was it cleaned? 11Yes 11 No 5. Observed condition of component pumped: Normal- water loa-el 12i hottom sludge lin top solids Roth baffles are intact Mdin tine etedr. No ft1t:e!L is present on t:he tank; cuLrent tdiik is rlot designed to e used with a filter. Cover(s) secured. No 3rd party paperwork filled. covers, 8000 gallons. NOT 4000. 6. System Pumped By: Justin Beaudoin Name Vehicle License Number Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752 Company 7. Location where contents were disposed: Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 P---- 03/11/2022 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1