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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 946 OSGOOD STREET 4/19/2022 �"Ec� j Commonwealth of Massachusetts R 19ti4�� T� City/Town of North Andover PQ ovE�` System Pumping Record N;, +,� MEND Form 4 cOWN� P� DEP has provided this form for use by local Boards of Health.Other forms may be used,but the info6i n 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 Osgood 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 Date 11/02/2021 2. Quantity Pumped. Gaallonsllons 000 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: e used with a filter. Cover s secured. No 3rd party paperwork i e . Pumped gallons of grease. 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: Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA 11/02/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1