HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 757 TURNPIKE STREET 7/26/2021 Commonwealth of Massachusetts RECEIVED
W City/Town of North Andover 6 2021
System Pumping Record �uL 2 AN
opvER
Form 4 10WNOTNpEP RTMENT
NEP
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
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 757 Turnpike Street
key to move your Address
cursor-do not North Andover MA 01845
use the return - - - - —---
key.
City/Town State Zip Code
2. System Owner:
r� Stop & Shop
Name -- - - --- - _
ieMn
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
Telephone Number
B. Pumping Record
18..21
1. Date of Pumping 5.- - - - 2. Quantity Pumped: 8000
-
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. 18in bottom sludge. 1 in top solids. Both baffles are intact. Main line Clear. No
filter is present on the tank. Cover(s) secured. Pumped 8000 gallons._._
6. System Pumped By: i
Marcus Lark l ��
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
WSG
3.1.21
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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