HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 757 TURNPIKE STREET 12/12/2022 ;1ECEIVED
Commonwealth of Massachusetts
City/Town of North Andover DEC 12 2022
A System Pumping Record
Form 4 TOWN OF NORTH ANpOVEP
u� PARTMENT
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the inforrti�[Ion m stt 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:
757 Turnpike Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
C&W Services/Stop & Shop -
Name
117 Kendrick Street, Suite 250
Address(if different from location)
Needham Heights MA 02494
City/Town State Zip Code
5714342034 x
Telephone Number
B. Pumping Record
1. Date of Pumping 11/01/2022 2. Quantity Pumped: 8000.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank ❑Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? M Yes W] No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
Narmal waterle of 6in hattom sludge 2;n tap gQ1ids Bath baffles are intact
Main tina Ctear. No filtt�r is present on t:lie taiik; current: tank is nat designed to-
e used with a filter. Cover(s) secured. No 3rd party paperwork i e .
6. System Pumped By:
Jay Beaudoin
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780
11/01/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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