HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 267 CHICKERING ROAD 2/10/2023 BECENED
Commonwealth of Massachusetts FEB 10 ZOD
City/Town Of North Andover E
System Pumping Record -MR. �
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:
267 Chickering Road,
Address
North Andover MA 01845
City/town State Zip Code
2. System Owner:
Ninety Nine Restaurant
Name
14A Gill Street,
Address(if different from location)
Woburn _ _ MA 01801
City/rown State Zip Code
7819325163 x
Telephone Number
B. Pumping Record
1. Date of Pumping 01/27/2023 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) 0 Septic Tank F1 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:
Not Applicable water nin bottom sil.1cigen• i-op solids Main 1 'me Nnt
1—
used with a filter. over s secured. No 3rd party paperwork filled. umpe catch
basins.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
NENO Yard: 163 Western Ave, Gloucester, MA 01930
01/27/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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