HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 93 TURNPIKE STREET 12/12/2022 � Commonwealth of Massachusetts
City/Town of North Andover
a 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 b
substantially the same as that provided here.Before using this form,check with your local Board of Health to M ����f�
A�m'e-me 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: TOWN OF NORTH ANDOVER
93 Turnpike Road HEALTH DEPARTMENT
Address
North Andover MA 01845
Cityrrown 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 10/12/2022 _ 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 R1 No If yes, was it cleaned? Yes 0 No
5. Observed condition of component pumped:
Normal- .,at 2i-n battaw sl,iclge8i14tGp solids Inlet baffles are i t r
e used with a filter. Cover(s) secured. No 3rd party paperwork i e . Water leve
normal no filter present mainline clear baffles intact light solids and sludge
pumped 3000 gallons of grease cover secured.
6. System Pumped By:
Geoffrey Howard
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780
10/12/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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