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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 700 CHICKERING ROAD 4/19/2022 ijeC V�0 Commonwealth of Massachusetts R 19101� T City/Town of North Andover A� N0aSN ZMENS R System Pumping Record 10\NVAOf ID PPS t Form 4 HEP 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 City/Town 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 9786831300 Telephone Number B. Pumping Record 1. Date of Pumping 11/13/2021 2. Quantity Pumped: 1000.0000 Date Gallons 3. Component: Cesspool(s) © Septic Tank Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes © No If yes, was it cleaned? ❑Yes No 5. Observed condition of component pumped: Nnrmal Wafe, i i rin bn++ gi H .soliag gct:h baffles are intact e used with a filter. over s secured. No 3rd party paperwork i e . 1000 gallons pumped. 6. System Pumped By: Jason Tedesco Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: NEMO Yard: 54 Knox Trail, Acton, MA 01720 11/13/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1