HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 267 CHICKERING ROAD 10/3/2022 �ECE�VE1;
Commonwealth of Massachusetts 3 2022
City/Town of North Andover OAT
System Pumping Record OF Nv��"ANcoT�
Form 4 TOHEP&JOIDEpARTMEN'
w a 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 ip Code
2. System Owner:
Ninety Nine Restaurant
Name
14A Gill Street,
Address(if different from location)
Woburn MA 01801
City/Town State Zip Code
9783728203 x
Telephone Number
B. Pumping Record
1. Date of Pumping 08/11/2022 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 0 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
Nermal swat';!r Gin hartnm 21-u tge gin to Solids Main line Clear No f;1for
secured. No 3rd party paperwork i e .
6. System Pumped By:
James Pepin
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
08/11/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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