HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 93 TURNPIKE STREET 3/21/2022 Commonwealth of Massachusetts �1101�
City/Town Of North Andover MP N %A
a System Pumping Record �NOF oEPP
Form 4 10 NF,p'%J(A
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
City/Town State Zip Code
2. System Owner:
Rubicon (PCS)
Name
125 Half Mile Road, Suite 201
Address(if different from location)
Red Bank NJ 07701
City/Town State Zip Code
7322753434 x
Telephone Number
B. Pumping Record
1. Date of Pumping 02/15/2022 2. Quantity Pumped: 3000.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank ❑X Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? M Yes 0 No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
Normal- water I-evel- 3in h=to rl-d e 4in top solids Beth baffles are intact
Main iine Cled-L. Nu filtez is present on the tank; uurrerit tarik L;dil be outfitted!
with a i ter. Cover(s) secured. No 3rd party paperwork i e . Heavy solids an
sludge no filter present pumped 3000 gallons covers secure.
6. System Pumped By:
Anthony Snow
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
02/15/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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