HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 99 TURNPIKE STREET 10/10/2023 Commonwealth of Massachusetts
City/Town of North Andover
o System Pumping Record 4C� 14
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:
99 Turnpike Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
d/b/a B. Good Millennial Foods Inc.
Name
140 Glastonbury Boulevard
Address(if different from location)
Glastonbury CT 06033
City/Town State Zip Code
8572856970
Telephone Number
B. Pumping Record
09/12/2023 100.0000
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) a Septic Tank Fj Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? M Yes ❑X No If yes, was it cleaned? ❑Yes 11No
5. Observed condition of component pumped:
[3 Bay Sink] : . Stalis. 10" H2O. 2" SOL. 2" GRS. Gasket OK. BOH logs signed. Extra
Services : . Pumped and cleaned. Did you check in and out? : Unchecked. No
signature/store stamp.
6. System Pumped By:
Vilton Marques
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
09/12/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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