HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 700 CHICKERING ROAD 12/12/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record ToHEALTHDEP �R
Form 4
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 Chickerinq Road,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Ashland Farm at North Andover
Name
700 Chickerinq Road,
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
6035050630 x
Telephone Number
B. Pumping Record
1. Date of Pumping 11/22/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) 0 Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes ❑X No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
u ai watere ei 5i-n bnt t sludge 3in top—solids Both haffles are intact
maill line elear. No filte-L i's present: un Lhe tanki UUL.Lellt tank is nat designed
e used with a filter. Cover s secured. No- 3rd party paperwork i e .
6. System Pumped By:
Michael Graham
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
11/22/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1