HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 267 CHICKERING ROAD 12/12/2022 RECEIVED
Commonwealth of Massachusetts
--__ - City/Town of North Andover DEC 12
System Pumping Record TOyE�TNpEpgRTM LATER
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
City/Town State Zip Code
2. System Owner:
---- Ninet-V Nine- Restaur-ant - ---- - -- -- - - —
Name
14A Gill Street,
Address(if different from location)
Woburn _ MA 01801
City/Town State Zip Code
7819325163 x
Telephone Number
B. Pumping Record
1. Date of Pumping 11/23/2022 2. Quantity Pumped: 3500.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank ❑Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes FjV-j No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
Norma] water le"Q] Si-n bcttaw sludge12in t;Gp solids Path bafflesare rotas*
Maiii time Cieci.L. Na fttter is pLesmit UIL the- tduki uu-rrent tank is nut designed LCT--
e used wit a i ter. Cover s secured. No 3rd party paperwork i e . Water eve
normal no filter present mainline clear baffles intact light solids and sludge
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
11/23/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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