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HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 93 TURNPIKE STREET 7/26/2021 Commonwealth of Massachusetts RECEIVED City/Town of North Andover JUL. ? 6 2021 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT 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: 93 Turnpike Road Address North Andover MA 01845 Cityrrown State Zip Code 2. System Owner: Rubicon Name 125 Half Mile Road, Suite 201 Address(if different from location) Red Bank NJ 07701 City/Town State Zip Code 7322753434 Telephone Number B. Pumping Record 1. Date of Pumping 06/26/2021 2. Quantity Pumped: 3000.0000 Date Gallons 3. Component: Cesspool(s) ❑ Septic Tank ❑Tight Tank ©Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes © No If yes,was it cleaned? ❑Yes ❑ No 5. Observed condition of component pumped: Normal water > > 3ip h rtom sludge-. 4itop—solids Inlet baffles are intact e used with a filter. over s secured. No 3rd party paperwork i e . Water eve normal, no filter present, pumped 3000 gallons of grease, cover secured. 6. System Pumped By: Geoffrey Howard Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: NEMO Yard: 54 Knox Trail, Acton, MA 01720 �/'✓— 06/26/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1