HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 700 CHICKERING ROAD 6/7/2024 <�, Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
M 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:
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
9786831300
Telephone Number
B. Pumping Record
1. Date of Pumping 06/07/2024 2. Quantity Pumped: 100.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank FX—] Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes FX-] No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
[3 Bay Sink] : . Needs to be replaced. 4" H2O. 4" SOL. 4" GRS. Gasket OK. BOH logs
signed. Extra Services : . Pumped and cleaned trap. Did you check in and out?
Unchecked. Got signature/store stamp.
6. System Pumped By:
Amauary Leon I
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780
06/07/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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