HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 757 TURNPIKE STREET 4/11/2023 (3) KECE�v��f
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System Pumping Record
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:
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
4017273400
Telephone Number
B. Pumping Record
1. Date of Pumping 03/16/2023 2. Quantity Pumped: 4000.0000
Date Gallons
3. Component: ❑ Cesspool(s) 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:
Normal water level. 1000in bottom sludge. 1000in top solids. Both baffles are
intact. Main line Clear. No filter is present on the tank; current tank can be
outfitted with a filter. Cover(s) secured. No 3rd party paperwork filled. Removed
4000 manager Rolando signed at my tablet 9:33 am.
6. System Pumped By:
Ronnie Soucie III
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
03/16/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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