HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 267 CHICKERING ROAD 7/6/2022 RECEIVED
Commonwealth of Massachusetts JUL 0 6 2022
City/Town of North Andover
OF NORTH
System Pumping Record TOWN
OHEALTH DEPARTMENTER
Form 4
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:
267 Chickering Road, Rte 125
Address
North Andover MA 01845
Citylrown State Zip Code
2. System Owner:
Ninety Nine Restaurant
Name
14A Gill Street,
Address(if different from location)
Woburn MA 01801
Cityrrown State Zip Code
5088219922 x
Telephone Number
B. Pumping Record
1. Date of Pumping 05/26/2022 2. Quantity Pumped: 3500.0000
Date Gallons
3. Component: Cesspool(s) F)-(] Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes ❑X No If yes, was it cleaned? El Yes 0 No
5. Observed condition of component pumped:
_Norma_ + la—al— Rin hottam 21iidge i 2In top so-lids —Both haffles are •nt +
e used wit a i ter. Cover(s) secured. No 3rd party paperwork i e . Water leie
normal no filter present mainline clear baffles intact heavy solids and sludge
back washed lx pumped 3500 gallons of grease cover secured.
6. System Pumped By:
Geoffrey Howard
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
05/26/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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