HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 757 TURNPIKE STREET 10/10/2023 Commonwealth of Massachusetts oEp�R�M`Na
= City/Town of North Andover H�'�'�N
System Pumping Record lotion
Form 4 OL
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
2032381235
Telephone Number
B. Pumping Record
1. Date of Pumping 09/08/2023 2. Quantity Pumped: 600.0000
Date Gallons
3. Component: ❑ Cesspool(s) 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:
[Bakery] : . Plastic. Good condition. 6" H2O. 4" SOL. 4" GRS. Left 0 btl solution.
Gasket OK. BOH logs signed. Extra Services . [Mop Sink] : . Metal. Heavy rust. 4"
H2O. 4" SOL. 4" GRS. Left 0 btl solution. Replace gasket. BOH logs signed. Extra
Services : . [Meat] : . Metal. Heavy rust. 10" H2O. 2" SOL. 2" GRS. Left 0 btl
solution. Replace gasket. BOH logs signed. Extra Services [Seafood] : . Metal.
6. System Pumped By:
Andrew Malabre
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
09/08/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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