HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 93 TURNPIKE STREET 7/26/2021 (3) Commonwealth of Massachusetts
W City/Town of North Andover RECE�VE�
System Pumping Record
Form 4 ZHANODvER
TOWN DF NDR H DEPP RTMENT
T
DEP has provided this form for use by local Boards of Health. Others 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
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 93 Turnpike Road
key to move your Address
cursor-do not North Andover _ MA_ 01845
use the return City/Town State Zip Code
key.
t-71 2. System Owner:
Chlpotle-- -
Name
reran
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
Telephone Number
B. Pumping Record
2.22.21 3000
1. Date of Pumping - - 2. Quantity Pumped: - -
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 level. 2in bottom sludge. 4in top solids. Both baffles are intact. Main line Clear..
Cover(s) secured. Heavy solids and moderate sludge no filter present pumped 3000 gallons
6. System Pumped By:
Anthony Snow
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
WSG
2.22.21 ---- -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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