HomeMy WebLinkAboutSeptic Pumping Slip - Ninety Nine - 11/07/2024 - Septic Pumping Slip - 267 CHICKERING ROAD 11/7/2024 Commonwealth of Massachusetts
City/TownOf North Andover
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:
267 Chickens Road., Rte 125 ..........
Address
North Andover MA 01845
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2. System Owner:
Ninetv Nine Restaurant
Name
14A Gill Street
Address(f-�djr�aii i different from location)
Woburn MA 01.8.0 1---
City/Town State Zip Code
9783728303
Telephone Number
B. Pumping Record
1. Date of Pumping 11 0 7 2 0 2 4 3500.0000
- 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) F] septic Tank F]Tight Tank ®Grease Trap
F] Other(describe):
4. Effluent Tee Fitter present? Yes Q No If yes,was it cleaned? F-]Yes ❑ 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. 3500 gallons removed. 2 inches of
bottom sludge. 6 inches of grease on top. 48 inches of water. System is at proper
working level. Both baffles/tees are intact. Main line is clear. Na.
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:
South essex sewerage district: 50 Fort Ave, Po Box 989, Salem MA 01970
Robert Herrick 11/0 7/2 0 2 4
Signature of Hauler Date
Signature f Receiving Facility(or attach facility receipt) Date
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