HomeMy WebLinkAbout- Septic Pumping Slip - 267 CHICKERING ROAD 3/6/2023 r�EC�`v�V
Commonwealth of Massachusetts 3
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City/Town of North Andover ��QR hNVpV�
System Pumping Record pFNO P�10
Form 4 �p�NN�p�jvAVE
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the infori`l[ion 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:
Ninety Nine Restaurant
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 02/13/2023 2. Quantity Pumped: 3500.0000
Date Gallons
3. Component: ❑ Cesspool(s) 0 Septic Tank ❑Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes n No If yes,was it cleaned? ❑Yes No
5. Observed condition of component pumped:
Normal water level. 3in bottom sludge. 6in top solids. Both baffles are intact.
Main line Clear. No filter is present on the tank; current tank is not designed to
be used with a filter. Cover(s) secured. No 3rd party paperwork filled.
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
02/13/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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