HomeMy WebLinkAboutSeptic Pumping Slip 1°ltV. /1
�r
Commonwealth of Massachusetts NOV 26 2024
City/Town of North Andover �.�EyY � R
-_ 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
Cityrrown State Zvi 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 09/16/2024 2. Quantity Pumped: 4000.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes 0 No If yes,was it cleaned? Yes Fj No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Grease Tank system serviced. Filter not
present. Tank cannot be outfitted with filter. 5000 gallons removed. 1 inches of
bottom sludge. 1 inches of grease on top. System is at proper working level. Both
baffles/tees are intact. Recommend increasing pumping frequency. Main line is
clear.
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
Robert Herrick 09/16/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1