HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 700 CHICKERING ROAD 3/6/2023 HEG�tV��
Commonwealth of Massachusetts
City/Town of North Andover ,.
m� System Pumping Record oojEa
Form 4
° v DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must,t a
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 Chickering Road,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Ashland Farm at North Andover
Name
700 Chickering 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 02/13/2023 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X 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:
Normal water level. 2in bottom sludge. lin top solids. Outlet 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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